There have been numerous reports of short-term follow ups in hemofiltration (HF), but only a few have reported on long-term ones. The purpose of this article is to report the case of an old man who has been undergoing HF for about 26 months after 2 years of hemodialysis (HD), and the phenomenon of an abrupt decrease in the blood glucose level during HF.
The 67-year-old man with diabetes mellitus (DM) was admitted to our hospital due to chronic renal failure, diabetic retinopathy and neuropathy. He had been suffering from DM and treated with insulin for 25 years. The laboratory data showed BUN, 106mg/dl and s-Cr, 6.6mg/dl, indicating end-stage renal disease. After being hospitalized for 6 weeks he received HD, but we found it difficult to control his hypotension during HD with acetate dialysate and even with high sodium or bicarbonate dialysate. Therefore, we transfered him from HD to HF (Sartorius, Hemoprocessor-Hemofilter; Simizu, HF Solita^®). Immediately after the transfer to HF, the frequency and severity of hypotension decreased markedly. In addition there were no serious side-effects of the HF during about 26 months of treatment, except a slight increase in the s-Cr level. There was an abrupt decrease in the blood glucose level during HF. This proved to be due to the fact that the substitution fluid contained no glucose. It is well known that in DM the sharp fluctuations in the blood glucose level aggravate diabetic complications. The addition of glucose to the substitution fluid induced a slight and smooth change in the blood glucose level during HF similar to that of a non-HF day. Therefore it is very important with HF to use a substitution fluid containing glucose.
This case demonstrates that HF is very effective in cases having hypotensive tendencies during HD, that HF probably does not cause any remarkable side-effects when used over a long period, and that it is very important to perform HF with a glucose-containing substitution fluid, particularly in DM in view of the progression of diabetic complications.

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Cellular immunity in hemodialysis patients and continuous ambulatory peritoneal dialysis (CAPD) patients was studied with regard to natural killer cell activity (NK activity) and to the antibody-dependent, cell-mediated cytotoxic activity (ADCC activity) of killer cells. To investigate the effect of hemodialysis, the NK and ADCC activities were determined before and after hemodialysis.
Twenty hemodialysis patients (16 male, 4 female) and 7 CAPD patients (5 male, 2 female) were included in this study. The hemodialysis patients' ages ranged from 13 to 79 years (mean=50.2) and the CAPD patients' ages ranged from 27 to 67 years (mean=46.7). Six healthy subjects were also studied to compare the results. There was no relation between NK activity and duration and age in either hemodialysis patients or CAPD patients. And there was no relation between ADCC activity and duration and age in hemodialysis patients and CAPD patients. The NK activities in hemodialysis patients were 19.6%±6.5% and were significantly decreased compared with 36.4%±14.8% in normal subjects (P<0.001). The ADCC activities in hemodialysis patients were 54.7%±10.4% and were also significantly decreased compared with 71.4%±4.2% in normal subjects (p<0.01). No differences with regard to NK activity and ADCC activity were observed between hemodialysis patients and CAPD patients, or between normal subjects and CAPD patients.
In 5 patients there was no difference in NK activity before and after hemodialysis, but the ADCC activity was 65.2%±2.9% before hemodialysis and 52.4%±5.6% after hemodialysis-a significant difference (p<0.01). The present study comfirmed that hemodialysis is not able to improve NK activity, and it showed a deterioration of the ADCC activity with hemodialysis.

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Continuous ambulatory peritoneal dialysis (CAPD) has recently been introduced as an alternative hemodialysis for patients suffering from chronic renal failure. Unfortunately this therapy is accompanied by a high incidence of peritonitis. Fungal peritoneal infection after repeated antibiotic courses has been noted previously. We report a case of a patient who contracted fungal peritonitis not resulting from bacterial peritonitis. A 40-year-old man with a history of IgA nephropathy advanced to end-stage renal disease in August 1977 and he was introduced to hemodialysis therapy. CAPD treatment was initiated in March 1983. His condition was favorable. However, he contracted peritonitis for the first time in November 1984. A PAS stain of the peritoneal fluid and a culture proved the presence of Candida guilliermondii, and candida peritonitis was diagnosed. Immediately, the peritoneal catheter was removed and intravenous amphotericin B treatment was begun. These strategies cured his peritonitis. It was suspected that the patient caught the fungus from his pet cat, thus causing fungal peritonitis without a preceeding bacterial peritonitis. It appears to be important to protect CAPD patients from infection by animals. We also evaluated the cell-mediated immunity in this patient, but found no significant decrease compared with normal controls. In summary, PAS staining of peritoneal fluid in addition to a culture are useful for early diagnosis because the possible contamination by normal flora in the atmospere needs to be ruled out in peritoneal fluid culture.

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From June, 1978 through July, 1986, 22 cancers were diagnosed in twenty patients under maintenance hemodialysis. The mean patient age at induction of hemodialysis and diagnosis of cancer were 52.90±8.72 years (range 34 to 67 years) and 56.95±8.53 years (range 41 to 68 years), respectively. The mean duration of dialysis before diagnosis of cancer was 4.05±8.56 years (range 7 months to 11 years). Gastrointestinal cancers were found in 9 (45.0%) of 20 patients including four in the stomach, three in the rectum and two in the ascending colon. Of these patients having stomach cancer, one patient was found two cancer in stomach and bladder both. Lung, liver, kidney and bladder cancers were found in two patients each, and thyroid, larynx and ovarium cancer, and leukemia were found in one patient each. The two kidney cancers were renal cell carcinoma with acquired cystic disease of the kidney (ACDK). One of them was double cancers in both kidneys. In our experience, direct causes of death in hemodialysis patients with malignancy were mainly underdialysis, malnutrition, infection and bleeding.

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Platelet dysfunction observed in introductory hemodialysis (HD) patients with chronic renal failure, such as bleeding and decreased platelet aggregation, is improved by HD, and these abnormalities are not seen in maintenance HD patients. However, in HD patients, platelets are thought to be somewhat affected by extracorporeal circulation and uremic toxins, although this is not detected clinically. In this study, platelet dysfunction in maintenance HD patients was evaluated by platelet enzyme activity. Thirty-four healthy volunteers, 30 maintenance HD patients and 21 CAPD patients were selected for this study. Platelet aggregation (collagen 2μg/ml), Mg⁺⁺-ATPase activity, K⁺ -EDTA ATPase activity and platelet cyclo-oxygenase (PCO) activity using the platelet malondialdehyde (MDA) production rate were measured, and the following results were obtained: 1) Platelet aggregation was not different among the three groups. 2) Mg⁺⁺-ATPase activity was 7.0±1.3, 5.7±1.5 and 6.2±1.7nmol Pi/mg protein/min in the healthy subjects, HD patients and CAPD patients, respectively. It was significantly lower in the HD and CAPD patients compared with the healthy subjects (HD: p<0.005, CAPD: p<0.05) but was not different between the two patient groups. 3) The MDA production rate was 13.3±2.0, 8.3±2.0 and 9.6±1.2nmol/10⁹ platelets in the healthy subjects, HD patients and CAPD patients, respectively, and was significantly lower in the two patient groups compared with the healthy subjects (HD: p<0.001, CAPD: p<0.001). Moreover, it was significantly lower in the HD patients compared with the CAPD patients (p<0.05). 4) K⁺-EDTA ATPase activity was lower than Mg⁺⁺-ATPase activity, and the three groups could not be compared. These results indicated that platelet dysfunction is improved by blood purification but is still present even in maintenance dialysis patients, though it is not observed clinically. Furthermore, it was found that platelets are less affected by CAPD compared with HD.

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Purpose: To clarify the hemodynamic characteristics of patients experiencing a hypotensive attack during hemodialysis (HD), and predicting the attacks, Subjects: Twenty-eight patients with chronic renal failure without any signs of heart failure. Methods: An impedance cardiogram, carotid pulse waves, ECG, and PCG were recorded simultaneously during hemodialysis. The mean thoracic impedance (Zo), stroke volume (SV), cardiac index (CI), total peripheral resistance (TPR), and the systolic time interval were measured immediately before and after HD and every 30min thereafter, 12 times in total. The subjects were classified into the S group, with stable blood pressure during HD, and the D group, with a hypotensive attack during HD. The time-course changes in each of the parameters were compared between the 2 groups. Results: There were 19 S-and 9 D-group subjects. In the D group, a hypotensive attack occurred in the middle stage of HD (between 2 and 3h) in 3 cases and in the late HD stage (between 4 and 4.5h) in 6 cases. Before HD, the Zo was significantly higher in the D than in the S group, while the SV and CI were significantly lower in the D group. The two groups showed no significant differences in blood pressure, HR, Zo, dZ/dt min., SV, CI, TPR, or PEP before the hypotensive attack (4h after initiation of HD). Between 3.5 and 4h after initiation of HD, the decreases in ΔsBP and ΔmBP, prolongation of ΔPEP, shortening of ΔETc, and decrease in ΔET/PEP in the D group were significantly larger than in the S group.
Discussion: It is difficult to predict hypotensive attacks during HD. In our study, the 2 groups showed no significant differences in blood pressure, SV, CI, or TPR before the attack, but abnormalities in the systolic time interval were present 30min before the attack in the D group. Thus, a circulatory failure state was already present 30min before onset of the hypotensive attack. Prediction of hypotensive attacks during HD by detecting such systolic time interval abnormalities should be possible.

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We measured Ca⁺⁺ in lymphocytes, Ca⁺⁺ influx, and transformation of lymphocytes after stimulation with phytohemagglutinin (PHA) in patients with chronic renal failure (CRF).
Lymphocytes were taken from 24 patients with CRF and from 10 normal healthy people. The uremic patients were separated into two groups-12 on short-term maintenance hemodialysis (SHD group) and 12 on long-term HD (LHD group). The Ca⁺⁺ in lymphocytes was measured with the fluorescent indicator Quin 2.
In the normal controls, the Ca⁺⁺ in lymphocytes was 127.1±17.1nM at 0min after PHA stimulation, 169.6±42.1nM at 30min, 221.6±50.5nM at 60min. The Ca⁺⁺ concentration tended to increase with time in all groups. In the SHD group, Ca⁺⁺ in lymphocytes were lower at 30min (145.9±45.9nM) and 60min (190.0±65.2nM) compared to the controls, but these values were not statistically significant. The increases of Ca⁺⁺ influx after PHA stimulation were 338.3±65.3nM in the normal controls, 301.4±83.7nM in the SHD group, and 352.5±142.5nM in the LHD group. The differences among the three groups were not significant. The mean transformation index (TI) resulting from PHA stimulation was 13.7±7.4 in the controls and 17.5±11.3 in the HD patients. These were not significantly different.
Thus, once lymphocytes were separated from the “toxic” serum of uremic patients, they reacted almost normally and we found no functional deterioration in lymphocyte proliferation and intracellular Ca⁺⁺ concentration. Therefore it appears that so-called immune deficiency in uremic patients rerults from the reversible dysfunction of lymphocyte caused by uremic toxins and from the decrease in lymphocyte population.

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In recent years, the occurrence of colo-rectal cancer has increased markedly in Japan because of the westernization of dietary regimens and a decrease in dietary fiber intake. Hemodialysis patients usually receive high-protein and high-fat diets and they tend not to eat enough vegetables and fruits. The present study deals with elevated lesions of the colon and the rectum in hemodialysis patients detected by examination of the lower digestive tract. Roentogenological and endoscopic examinations of the colon and the rectum were conducted in 81 patients on maintenance hemodialysis (55 males, 26 females) from September 1981 to June 1986 at Kojin-kai Central Hospital. The results are as follows: 1) Elevated lesions of the colon and the rectum appeared in 27 patients (46 lesions). Eight colo rectal cancers appeared in 6 patients, three of whom underwent surgical operation because of advanced cancer. 2) Thirteen patients (20 lesions) had endoscopic polypectomies and 2 patients (2 lesions) had surgical polypectomy of colo-rectal polyp. Early cancer was found in 3 of these patients. Postpolypectomic hemorrhage, which occurred in 3 patients, was controlled by conservative therapies. Perforation due to endoscopy occurred in 1 patient during the examination and a surgical operation was performed immediately. 3) Twenty-eight colo-rectal adenomas were found in 19 patients. Of these, 21 were larger than 5mm. 4) Most of eighteen patients with colo-rectal cancer, as well as adenoma over 5mm in size, were over 51 years of age and had been maintained on hemodialysis for longer than 4 years. The examination were initiated in 9 patients because of anal hemorrhage or blood in the feces. 5) There were forty-six lesions of the colon and the rectum, involving carcinoma, adenoma, leiomyoma and non-identifiable tissue. Twenty-two (48%) were located in the lower colon; 12 (26%) in the sigmoid colon; and 10 (22%) in the rectum. Elevated lesions of the colon and the rectum, which are detected by hemorrhage, occur frequently in hemodialysis patients. Therefore, examination of the lower digestive tract, as well as careful history-taking and digital examination of the rectum are important in these patients. Since dialysis patients usually take low-fiber and high-fat diets and tend to be constipated, special attention should be paid to the occurrence of colo-rectal cancer. A further study is needed to determine whether hemodialysis patients carry a high risk of colo-rectal cancer.

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Of 128 patients who were introduced into hemodialysis between January 1969 and June 1976 at our institutes, 62 have survived over 10 years. The cumulative survival rates were 50% for 10 years, 42% for 15 years and 25% for 17 years. Nine of them died and the causes of death were disturbence of cerebral vessels in 5 cases, hyperkalemia or sudden death in two cases, myocardial infarction in one case and sepsis after bone fracture in one case.
We analysed the state of rehabilitation with regard to symptoms and renal osteodystrophy (ROD) in 48 patients who had survived until June 1986. The state of rehabilitation was 54% in full time workers, 10% in part time workers, 19% in full time house workers and 4% in retired men. The overall rehabilitation rate was 87%.
Symptoms of ROD were pain during movement of joints, 42%; spontaneous skeletal pain, 23%; muscle weakness, 67%; and pathological fracture, 2%. Carpal tunnel syndrome (CTS) appeared in 19% of the patients. The conditions accompanying failure in rehabilitation were mainly ROD and CTS.
Both microdensitometer (MD) scores and osteocalcin (OC) levels were positively correlated with duration of hemodialysis and they were statistically significant. No correlations were found between duration of hemodialysis and other factors such as PTH, serum Al-P and serum Al levels.
Parathyroidectomy (PTX) was performed in only one case. N-PTH levels over 350pg/ml were detected in 6 cases. Three of them had symptoms of ROD, but they were treated effectively with conservative therapy.
We conclude that the MD scores and OC levels are excellent parameters of ROD in patients with over 10 years of hemodialysis. We think that PTX should be carefully applied in ROD patients and that conservative therapy should be performed at an early stage of ROD.

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Many complications have been reported concerning the use of non-treated tap water for diluting concentrated dialysate. Recently, water purification systems, especially, reverse-osmosis systems have been widely used for this reason. We investigated the effect of treating water by reverse-osmosis on anemia in hemodialyzed patients, compared with a water treatment system without reverse-osmosis. In 10 out of 21 patients, hemoglobin levels apparently increased, and red blood cell counts and hematocrits values were also ameliorated during the period when using reverse-osmosis system. There were no statistically significant differences, however, in any of the biochemical and hematological parameters a in the present study. Further investigations are needed.

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After defining “short-time hemodialysis” as that given for 3 hours each time and 3 times in 1 week, we studied the effects of such short-time hemodialysis in all patients who desired it.
RENAK A-23 H (2.3m²) was used to dialyze male patients and RENAK A-15 H (1.5m²) for female patients. The short-time hemodialysis was administered at blood flow rates less than 200ml/min. Predialysis hemobiochemical data were compared in the patients who were treated for more than one year, and the causes of the deaths that occurred during the period were studied. Fifty-six of 58 hemodialysis patients desired the short-time hemodialysis, and 54 of them (96.4% of the applicants) received it. The predialytic hemobiochemical examinations after 1 year of short-time hemodialysis showed BUN 79.2±15.6mg/dl, Cr 13.0±3.20mg/dl, K 5.02±0.94mEq/l, Ht 20.6±3.70%, time-averaged BUN 58.9±11.3mg/dl. These were not significantly different (p<0.01) from the cases of customary hemodialysis (5 hours dialysis). The predialytic CTR after 1 year in the short-time hemodialysis group was 55.9±6.30%. This was significantly more (p<0.01) than it was in the cases of customary hemodialysis. Three of the 15 cases of death were directly related to dialysis, but they did not result from the short-time hemodialysis. The 2 cases which could not be shifted to short-time hemodialysis were 1 cases of taking excessive water and 1 cases of blood flow deficiency.
The hemobiochemical data indicated that the short-time hemodialysis may be feasible hemobiochemically, but further studies are needed regarding the significant increasing in CTR.

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