Seventy patients with chronic renal failure underwent surgical therapy for secondary hyperparathyroidism; the first 20 received subtotal parathyroidectomy and the other 50 total parathyroidectomy and parathyroid autotransplant in the forearm. In 12 of the 20 subtotal parathyroidectomy cases, identification and removal of four glands were possible. Among the 50 total parathyroidectomy and autotransplantation cases, five parathyroid glands were removed from one patient and four from the other 49. Preoperative image diagnosis was valuable for locating ectopic and supernumerary parathyroid glands and differentiating swollen parathyroid glands from tyroid tumors, which are a frequent complication. After the operation, serum calcium decreased rapidly, especially in the patients with severe bone change, and adequate calcium replacement therapy was necessary.
Two of the patients complained of persistent hyperparathyroidism postoperatively, and we considered the possibility of supernumerary glands in the neck. The grafted tissues in all cases functioned well: reimplantation of cryopreserved parathyroid tissue was unnecessary, and osteomalacia after parathyroidectomy was not seen clinically. Two of the 20 subtotal parathyroidectomy patients were submitted to re-exploration of the neck because of recurrence. Recurrence was also diagnosed in four of the 50 total parathyroidectomy and autotransplantation patients, and one of these four underwent excision of the transplanted parathyroid tissues under local anesthesia.
In our experience, total parathyroidectomy and autotransplantation is an adequate treatment for secondary hyperparathyroidism. This procedure has the advantage of ensuring sufficient parathyroid function. Furthermore, parathyroid function can be controlled by additional transplantation of cryopreserved tissue or by excision of grafted tissue under local anesthesia.

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Along with recent advances in hemodialysis technology, the increase of patients with chronic renal failure is becoming a serious social problem. While renal transplants the claimed to be the radical cure for these patients, the problem of carcinogenicity in long-term hemodialysis patients has become apparent of late.
Generally, it is reported that the immunity is lowered in patients with chronic renal failure. For example, seeing that the tuberculin reaction, delayed skin reaction or mixed lymphocyte culture reaction is lowered, immunological anomaly, in particular, lowering of cellular immunity has been suggested. On the other hand, it is also reported that immunosuppressive substances are present in the sera of hemodialysis patients. These reports are very interesting when considered in relation to the problem of carcinogenicity. Accordingly, we studied the frequency of malignant neoplasm formation in hemodialysis patients and looked for the cause.
The incidence of malignant neoplasms in hemodialysis patients was 3.4% (17/499), and this value was significantly higher as compared with the control group. When the malignant neoplasms were classified, cancers of the digestive system were found in 10 out of 17 cases (58.8%; three cases of gastric cancer, five cases of colorectal cancer, and two cases of pancreatic cancer). In Iymphocyte subset research using flow cytometry, OKM1⁺ cells were significantly lowered in hemodialysis patients, and a decrease of NK and K cells was suggested.
In the Iymphocyte stimulation test by PHA (phytohemagglutinin), similar responses were noted in hemodialysis patients and healthy subjects, but the suppression activity was significantly higher in the patients. That is, the Iymphocytes of the patients seemed to strongly suppress the PHA response of normal lymphocytes. In the sera of hemodialysis patients, meanwhile, there was a higher content of IAP, an immunosuppressive substance, than in the sera of healthy subjects.
Thus, in long-term hemodialysis patients, the incidence of malignant neoplasms is high, and the causes of this are considered to include lowering of NK and K cells, an increase of suppression activity, and an increase of immunosuppressive substances in the sera.

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The purpose of the present study is to evaluate the clinical importance of parenteral alkalizing drugs in patients with chronic renal failure. Some hemodialyzed patients showed excessive postdialytic alkalosis by conventional treatment using commercial dialysates. If this phencmenon persisted for a long period in conjunction with postdialytic hypercalcemia, the patients showed metastatic calcification and increment of Ca in soft tissues, and sometimes developed organ dysfunction. Thus, it is important that the control of acid-base levels of these uremic patients be done appropriately by a specific method and that the physician can protect patients from this hazardous complication. Now, we are able to control the acid-base balance by ingestion of alkalizing drugs. One of these drugs has come to be prescribed recently and is easy to drink. It is composed of 4.4g of sodium citrate dissolved in water, with the addition sugar as sweetener and the perfume of lemon. In this study, we administered these drugs to two groups of uremic patients: group I was under conservative therapy and group II under chronic hemodialysis treatment.
Although the degree of acidosis was reduced in all patients administered the drugs for two to four weeks, they also showed a significant and simultaneous increase in body weight, cardiothoracic ratio and mean blood pressure. Thus, it is necessary for the physician to evaluate the patient's ability to excrete renal sodium and precisely regulate the dose of alkalizing agents in each patient. On the other hand, group II patients could be controlled more easily than those in group I. The main reason for this discrepancy is thought to be the cardiovascular stability of hemodialyzed patients (group II). It was concluded that the parenteral administration of alkalizing drugs, especially sodium citrate, is a useful therapeutic method of controlling uremic acidosis in hemodialyzed patients.

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Introductory dialysis patients tend to be unstable not only physically but also mentally. Therefore, how the patient is approached at this time affects his entire therapy. We have been trying to perform balanced therapy and, at the same time, help the patients learn to accept it and to control it by themselves. In reality, however, it is difficult to achieve uniform therapy due to the difference in the level of the nurses' abilities and in each nurse's way of thinking. There is also a difference in the learning capabilities among the patients, and we have had difficulties obtaining good results. Therefore, we prepared a pamphlet and cassette tape explaining the basic principles of renal failure, the complications involved, the daily guidelines, diet and rehabilitation and applied them as part of the therapy.
One nurse was assigned to each patient from the beginning, and the therapy was started after the patients' mental and physical condition had stabilized. The tape was run at bedside during the stable periods. As a result, we were able to achieve the following: (1) perform uniform therapy; (2) shorten the time needed to learn the basics; (3) repeat the therapy as many times as necessary, and (4) shorten the duration of nurse duty. However, there were also problems, such as (1) lack in originality; (2) difficulty in understanding the patients' response and (3) lack of communication with the patients.
In the future, we hope to continue this therapy based on the tape and pamphlet, but increase personal counseling and undertake therapy suited to the needs of each patient.

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