Sixteen male patients were treated by STD of 3 to 4 hours duration thrice weekly using a hollow fiber dialyzer of 1.5 to 2.1m² surface area for more than 5 years.
Except for two part-time officers, the other 14 patients are performing full-time work 6 days a week and enjoying active and useful lives.
On blood chemistry examination, the mean predialysis serum creatinine level was higher than that of control cases on conventional 5-hour dialysis. However, no uremic symptom such as nausea, anorexia, bleeding tendency or uremic pericarditis has emerged.
Mean C-PTH level is also considerably high, but X-ray examinations have revealed only minimal abnormality of various types in 5 cases and only one other patient showed multiple fractures and osteosclerosis. No metastatic calcification has been detected in any case.
Nerve conduction velocities were mildly suppressed in most cases. However, no muscle weakness nor sensory disturbances developed.
Blood pressure has been well controlled within normal limits after dialysis, although electrocardiogram revealed ventricular ischemia in 6 cases.
Rapid ultrafiltration yielded rather frequent hypotensive complications in 6 cases, most of which have been easily overcome by application of bicarbonate dialysate and/or, continuous intravascular infusion of hypertonic saline.
In conclusion, STD is well tolerated and uremic symptoms can be satisfactorily controlled for long periods of time, if candidates are properly selected.

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It has been difficult to obtain an effective means of manual control of ultrafiltration, even though there are many patients in whom rate of weight loss for a given transmembrane pressure gradient (TMPG) is difficult to predict. The present study was undertaken to obtain an optimal TMPG by using mathematical methods.
The results indicated that (TMPG X duration of dialysis) correlated well with the weight loss observed during dialysis. The weight loss estimated by applying the regression line consistently agreed with that actually observed in the patients.

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The frequency and characteristics of urinary tract infection (UTI) in 236 maintenance hemodialysis patients were studied.
In one year, UTI accompancied by subjective symptoms was observed in 42 cases or 17.8% of the total, which was roughly equal to the rate of incidence of infections of other organs. When cases of pyuria only, not accompanide by subjective symptoms, were added, the frequency was as high as 76 cases or 32.2% of the total.
Maintenance hemodialysis patients possess a few unfavorable factors which may account for the occurrence of UTI, but frequently the causative disease, therapy, examination procedure, etc. causes the infection. For example, in the case of diabetic nephropathy, a neurogenic bladder due to diabetes mellitus and in the case of polycystic kidney, obstruction of the upper urinary tract or infection of the cyst caused by the cyst itself may be the cause, while such other factors as catheterization or administration of steroids may also be responsible. For the patients carrying these factors, the onset of UTI may trigger a worsening of the general condition and therefore early diagnosis and early therapy with sufficient vigilance are required.

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Serum 5α-dihydrotestosterone (DHT), testosterone (T), androstenedione (A), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin (PRL) were measured by radioimmunoassay, and serum zinc by the atomic absorption method, in 25 male patients with chronic renal failure undergoing hemodialysis.
DHT, T and Zn levels were significantly lower, while A was significantly higher in dialysed patients than in control subjects. T was correlated with DHT in the patients. When the duration of hemodialysis became longer, T, LH and FSH levels showed a tendency to be increased, but to a level lower than normal. There were no significant correlation between Zn, or duration of hemodialysis, and A/T+DHT, but there was a significant correlation between T/DHT and duration of hemodialysis.
These findings may indicate that not only T but also DHT were responsible for gonadal dysfunction in male patients with chronic renal failure, that A to T conversion was diminished, and that no possible role of Zn in the metabolism of testosterone was found.

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CAPDs were applied in two patients with end-stage renal failure complicated with massive ascites which was refractory to hemodialysis and/or isolated ultrafiltration. Both patients were severely cachexic with anorexia during the hemodialysis period.
Glucose load from the dialysate, as well as improvement in appetite by relief of abdominal distension, apparently reversed the cachexia. Improvement in the nutritional state probably contributed to the successful treatment of the ascites. Our results suggest that CAPD might be a useful modality for controlling hemodialysis ascites.

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his is a case report of a patient who experienced a right quadriceps tendon rupture.
The patient, a 36-year-old female, has been suffering from renal osteodystrophy and secondary hyperparathyroidism. She has been undergoing hemodialysis treatment since March 1976. On February 7, 1984, a snowy day, she slipped and fell on the street hitting the right knee joint hard. She has complained of pain and difficulty in walking since then. She was admitted to the hospital immediately, whereupon X-ray findings showed a dislocation of the patella which was diagnosed as being a right quadriceps tendon rupture. On March 14, an anastomosis operation was performed under spinal anesthesia. The tendon was found to be completely ruptured. On May 23, a subtotal parathyroidectomy was performed under general anesthesia. A histological examination revealed parathyroid adenoma (excised organ weight 7, 500mg). The results of a bone biopsy revealed osteitis fibrosa.
The direct cause of the tendon rupture was the contusion she experienced when she slipped and fell on the street. However, it was largely due to the weakened condition of the tendon caused by secondary hyperparathyroidism and acidosis, both of which were caused directly by chronic renal failure.
Until recently cases of tendon rupture in hemodialysis patients have been relatively rare. However, nowadays, with the increase in long-term hemodialysis patients, corresponding increase in the percentage of such cases in quite possible. Sufficient care should be taken for patients undergoing hemodialysis treatment over a prolonged period.

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Suppression of immune responses in uremia and in hemodialysis is a well-known but poorly understood phenomenon. This study reports in vitro lymphocyte responses of 20 patients with renal failure due to glomerulonephritis, for 12 months following the induction of hemodialysis (HD). The patients were divided into two groups of 10 patients each based on the dialysis membrane used, a cellulose group and a PMMA group. Peripheral blood samples were taken immediately before and after the induction of HD and just before every HD. The T-cell response to phytohemagglutinin-P was evaluated by ³H-thymidine incorporation. After stimulation with pokeweed mitogen, antibody-producing cells were counted on a fluorescence-activated cell sorter (FACS IV). T-cell subsets were analyzed with the FACS IV by using monoclonal antibodies (Leu 2a and Leu 3a). Circulating immune complexes (CIC) quantified by the 3.5% polyethylene glycol (mol. wt; 6, 000) precipitation method.
The following results were obtained; (1) The T-cell response was reduced as time elapsed; percent inhibition was 18.2% at 14 days, 24.5% at 28 days, 58.3% at 6 months and 66.6% at 12 months. When the two groups were compared, the reduced response was seen in the PMMA group earlier than in the cellulose group (14 days versus 28 days). (2) There were no apparent changes in B-cell function and the Leu 3a/Leu 2a ratio. (3) CIC levels were reduced one day after the induction of HD in the cellulose group, but not in the PMMA group. However, they increased to the pre-induction levels on and after the 7th day after the first HD. (4) There was no significant change in the complement (C3 and C4) level. These results strongly suggest that reduced T-cell function is not related to the ratio of the T-cell subsets but is due to functional abnormalities associated with HD.

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A review of the experience with 48 patients on chronic hemodialysis who underwent abdominal surgical procedures is presented.
Abdominal procedures included 17 gastrectomies for bleeding gastric or duodenal ulcers (11 cases) and gastric cancer (6 cases); 9 appendectomies; 5 intestinal resections and 2 freeings of intestinal adhesion for ileus; 2 cholecystectomies; 2 splenectomies for splenomegaly; 2 hysterectomies for 1 uterine cancer and 1 bleeding myoma uteri; 1 combined abdomino perineal resection for rectal cancer; 5 intestinal resections for ischemic necrosis of the intestine and 3 others.
There was one operative death. Perioperative management of the patients, especially those who underwent gastrectomies is discussed.
Postoperative follow-up studies of gastrectomized patients with chronic renal failure were compared with those of the patients with normal renal function and it became clear that the former was definitely inferior in postoperative increase in body weight, improvement of anemia, physical activities and so on.
Therefore the postoperative hemodialysis patients require special consideration in their nourishment.
The most common complication after the surgery was congestive heart failure probably due to decreased cardiopulmonary function and overhydration based on diminished lean body mass or increased catabolism. This means that one of the most important factors after the surgery is how to determine the most appropriate body weight.
Modified blood purification methods such as SCUF (slow continuous ultrafiltration) and CAVH (continuous arteriovenous hemofiltration) caused essentially no symptoms in patients with highly disturbed cardiopulmonary function.
Ischemic necrosis of the intestines was observed in 5 cases and 6 resections of the necrotized intestines were carried out. Most of the patients did not always show serious abdominal manifestations which made the diagnosis difficult. All five patients were considered to have non occlusive ischemic disease because obstruction of a major intestinal vessel could not be documented in any case. All patients were hypotensive and the ultrafiltration volume was far beyond an appropriate limit in most hemodialyses, which further aggravated the hypotension.
It is contended that persistent hypotension, arterial disease and intestinal motility disturbances occurring in terminal uremic patients could be responsible for this complication.

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Recently plasma exchange (PE) with fresh frozen plasma (FFP) as replacement fluid has been widely applied in the treatment of hepatic failure patients. Since hepatic failure patients have a tendency foward alkalosis and hypernatremia, and FFP contains a large amount of citric acid and sodium, the alkalosis and hypernatremia can be worsened by PE in hepatic failure patients. In this study, the side effects of PE with special reference to that on acid-base balance and the beneficial effects of hemodialysis (HD) to correct those side effects were determined.
Of the 29 hepatic failure patients entering the study, 14 had viral hepatitis, 3 had drug-induced hepatitis, 3 cases had acute hepatic failure due to other causes, and 9 had postoperative hyperbilirubinemia. Blood gas analysis (BGA) and blood electrolyte analysis were performed before and after PE. Before PE (mean±SE, n=44), the pH was 7.47±0.01, HCO₃^- (mEq/l) was 27.4±0.7, BE (mEq/l) was 4.31±0.58, pCO₂ (mmHg) was 38±1 and pO₂ (mmHg) was 104±5, and after PE (n=44), the pH was 7.50±0.01, HCO₃^- was 28.8±0.8, BE was 6.10±0.50, pCO₂ was 37±1 and pO₂ was 109±6. These data indicate that PE worsened the alkalosis in hepatic failure patients.
Among the 29 patients, 5 patients had severe alkalosis and hypernatremia following the PE. For these patients, HD was performed 7 times to correct the PE. Before HD (equivalent to post PE), the pH ranged from 7.409 to 7.580, HCO₃^- ranged from 25.7 to 31.8, BE ranged from 3.8 to 9.6, and Na (mEq/l) ranged from 153 to 162. After HD, the pH ranged from 7.409 to 7.495, HCO₃^- ranged from 23.4 to 29.1, BE ranged from 1.3 to 4.5 and Na ranged from 140 to 155. These data indicate a beneficial effect of HD on alkalosis and hypernatremia after PE among hepatic failure patients.

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A thinner regenerated cellulose membrane is used in new hemodialyzers with longer outer shells. One of them was compared with the old type model, which has approximately the same surface area, from the aspect of solute and water removal capacity.
No significant differences were found in urea and creatinine clearances between the two models; however, the new model has a little higher clearance tendency depending on the dialysate flow rate in both solutes.
In uric acid and inorganic phosphate, the new model has not only a higher clearance but also a higher dependency of the clearance on the dialysate flow rate.
According to the relationship between clearance and the molecular weights of the small solutes, a thinner dialysis membrane seemed to be advantageous for removing larger solutes.
A thinner membrane also makes it possible to remove a larger amount of water. In clinical therapy, the transmembrane pressure (IMP) is set in accordance with the pseudo ultrafiltration coefficient (UFR/Pps) of the dialyzer. The real TMP decreases as the pressure drop increases with the dialysate flow rate. UFR/Pps must be controlled by such a means for clinical use of dialyzers.

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The psychosocial aspects and patient-therapist transactions in the field of dialysis therapy were discussed in this paper. The most important therapeutic factor is the patient-therapist relationship, but a phenomenon which often provokes therapeutical failure is countertransferance. A female patient in whom negative feelings and countertransference of the therapists including a medical social worker were evoked was presented. A woman aged 23 was diagnosed as having a strong tendency to personality disorder. Many behavior problems and troublesome symptoms were repeated; therefore the therapists had feelings of embarrasment, anger, aggression and selfdefense. Such feelings are unavoidable and being aware of one's own negative feelings toward the patient is important. Medical social workers shound be educated, experienced, and mature enough to be able to achieve this attitude.

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A 63-year-old man was treated by hemodialysis because the renal failure since Dec. 15′83 became uncompensated. Blood examination revealed that his peripheral leukocytes and platelets were very much above the normal values. During his hemodialysis, we frequently experienced the problem of obstruction of the dialyzer with blood coagulants. He was clinically diagnosed as having essential thrombocytosis, through extensive studies including his peripheral blood, bone marrow and other blood chemistry examinations. He complained of severe pruritus when dialyzed with “AM10, ” “AM100μ, ” “KF101” and “KF201” type dialyzers, whereas he had less pruritus when treated with a “B₂ 150” type dialyzer. As far as we looked for hematological changes during dialysis, we found some differences in the increase in his WBC counts from dialyzer to dialyzer. That is, his peripheral WBC increased significantly from 11, 200/mm³ to 24, 900/mm³ during HD with “AM10.” During HD with “KF101, ” his WBC increased from 10, 800/mm³ to 18, 400/mm³ (3 hr after dialysis). During HD with “B₂ 150, ” his WBC increased 11, 200/mm³ to 13, 200/mm³ (4 hr after dialysis). The increase in neutrophils was mainly responsible for his leukocytosis. We could not find any specific mechanism for these changes during HD.

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It has been generally accepted that cell-mediated immunity is decreased in chronic hemodialysis patients, and there are many such patients suffering from infectious diseases. In order to improve the prognosis of patients with chronic renal failure, it is important to evaluate in detail the cell-mediated immunity in those patients and determine the factors concerned with the impaired immunity.
The present report deals with mitogen-induced blastoid formation and subsets of peripheral blood lymphocytes from 79 chronic hemodialysis patients with chronic glomerulonephritis as well as 20 normal volunteers. PHA and Con A were used as nonspecific T cell mitogen. FITC-conjugated monoclonal antibodies specific for T cells (OKT-3), helper/inducer T cells (OKT-4), suppressor/cytotoxic T cells (OKT-8), and B-cells (B 1) were used for direct immunofluorescence staining, and the stained cells were analyzed on a flow cytometer (Ortho-Spectrum III).
The activity of T cells, as represented by mitogen response, was lower in chronic hemodialysis patients than in the normal controls. The peripheral lymphocyte count was lower but the OKT-3 positive cell rate was higher in chronic hemodialysis patients than in the controls. OKT-4/OKT-8 ratios in the patients and in the controls were 1.70±0.80 and 1.70±0.70, respectively; there was no significant difference.
When the group of chronic hemodialysis patients was divided into three subgroups on the basis of the OKT-4/OKT-8 ratio, the PHA response of the peripheral blood lymphocytes in the subgroup whose OKT-4/OKT-8 ratios ranged between 1.0 and 2.0 tended to be normal compared with that in the subgroups whose OKT-4/OKT-8 ratios were less than 2.0 or greater than 1.0.
When immunological parameters were compared between the patients undergoing hemodialysis for longer than 18 hours a week and for 15 hours a week, the former had higher OKT-4 positive cell counts than did the latter, though there was no significant difference in lymphocyte blastoid formation. Futhermore, the rate of OKT-3 positive cells showed a positive correlation with the number of hours of hemodialysis per week. These results suggest the possibility that the cell-mediated immunity in chronic hemodialysis patients is improved by prolonging the duration of dialysis.

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