Nutritional status and protein metabolism were studied in 8 continuous ambulatory peritoneal dialysis (CAPD) patients and the results were compared with those of hemodialysis patients. CAPD patients showed a lower BUN/creatinine ratio, on improved pattern of plasma free amino acids, and lower plasma level of branched-chain keto acids, as well as a relatively well maintained nutritional status. These results suggest that nitrogen-containing compounds are available for protein synthesis in CAPD patients.

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A case of tertiary hyperparathyroidism with parathyroid adenoma is reported. The patient was a 42-year-old female who had been on chronic hemodialysis for six years. She had a nodular tumor in the left anterior neck and abnormally high plasma levels of calcium, ionized calcium and parathyroid-hormone in a c-terminal assay. Radioisotope scintigrams with ²⁰¹TI showed a hot area, while scans with ^99mTc showed a cold area corresponding to the nodule in the left anterior neck. CT scanning also demonstrated a low-density mass with an unclear margin. Her neck was therefore explored. All of the four parathyroid glands were enlarged, the left upper one being most obvious. These four parathyroid glands were surgically extirpated because of the possibility of malignancy. Histologically, the left upper tumor showed adenoma with a fibrous capsule oppressing the normal tissue, but did not show malignant features such as mitosis or capsular invasion. The other three parathyroid glands showed hyperplasia.

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To clarify the cause of impotence in male chronic hemodialysis patients, we performed endocrinological examinations. We checked the serum testosterone level, salivary testosterone level LH level, FSH level, prolactin level and sex hormone-binding globulin level, and measured the testicular volume in each patient.
Serum testosterone levels of dialysis patients were significantly low. Salivary testosterone levels showed a wide range, and a tendency to be higher than in normal centrols. LH levels and FSH levels were high. Prolactin levels of patients under 50 years old were significantly higher than normal controls, but still usually within the normal range. There were no differences in prolactin levels between dialysis patients and normal controls in patients over 50. Dialysis patients showed a smaller testicular volume. Sex hormone-binding globulin levels were within the normal range and showed a significant correlation of Y=13.0X-30.8 with serum testosterone levels. It was surprising that salivary testosterone levels, normally thought to be a good indicator of free testosterone levels, were not low in parallel with the low levels of serum testosterone, and also that sex hormone levels showed a positive correlation with total serum testosterone levels. These findings suggest that the biologically active fraction of testosterone (i.e., free testosterone) is not lower in hemodialysis patients.
There were no findings suggesting a diagnosis of endocrinological impotence. Further research will be needed to clarify the cause of impotence in dialysis patients.

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In order to evaluate the changes ocurring in concentrations of valproic acid (VPA) during hemodialysis therapy, three patients, including two young children (less than four years old) were examined for their blood levels of total-VPA, free-VPA, free fraction (FF), BUN, creatinine, albumin and free fatty acid (FFA). Blood samples were obtained from an A-V fistula, before the initiation of dialysis, during dialysis (1, 2 hours) and, just prior to, as well as at the two hours after the termination of the dialysis. FF was 32.9±4.5% just prior to the initiation of dialysis which was higher as comparison with normal subjects previously reported. FF tended to be elevated just after the initiation of dialysis and was decreased after dialysis therapy. FF was reduced to minimum levels of 18.3±3.9% at two hours after the dialysis and it was sufficiently maintained for the effective treatment blood levels. FF was noted to be significantly positively correlated with the blood levels of FFA (r=0.66, p<0.01) and negatively with albumin (r=-0.52, p<0.05) but not with BUN and creatinine. In conclusion, VPA administered patients under hemodialysis must be controlled by measuring the free-VPA concentrations and if they are controlled solely through T-VPA, the changes in FF occurring through hemodialysis treatment should be taken into account.

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Remarkable hyperaldosteronemia (HA) (PAC>160ng/dl) has been recognized in about 20% of patients on long-term hemodialysis (HD) therapy in Japan. We have shown that the weight gain occurring after renal transplantation from live-related donors in non-nephrectomized recipients with remarkable HA was significantly higher than in other patients, and concluded that chronic and severe dehydration during HD therapy could cause remarkable HA. In the present study, the effects of increment of body weight (BW) on PAC, PRA and other clinical findings were investigated in 10 HD patients with remarkable HA. BW before and after HD was increased from 1.7±0.2kg (3.0±0.3%) to 2.0±0.2kg (3.6±0.4%), respectively. Hypotensive episodes during HD found in 7 patients were eliminated in all cases. CTR was increased (45.0±1.4→48.1±1.4%) and blood pressure before HD was elevated significantly in each patient. PAC and PRA before HD were decreased significantly (PAC, 331±48→119±17ng/dl, PRA 6.1±1.3→3.0±0.6ng/ml/h). A significant correlation was recognized between the rate of decrease of PAC and the rate of increase of BW. From these results, we conclude that chronic dehydration during long-term HD therapy causes remarkable HA (perhaps showing adrenal hyperplasia) which can be corrected by fluid replacement. Measurement of PAC and PRA may be useful for evaluating the dry weight of chronic HD patients.

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Serum levels of c-PTH (46-84h, Eiken Kit) were measured in 53 chronic renal failure patients at the initiation of their maintenance dialysis therapy. Then the levels were measured at a certain interval and the changes were analyzed. Serum c-PTH measured within a week before initiation of dialysis was 3.3±3.7ng/ml (mean±SD, n=53) ranging from 23.6-0.6ng/ml. In 11 out of 53 cases (20.8%), c-PTH was over 4ng/ml, which was tentatively taken to be a critical level of end-stage renal failure with a correlation to biologically active “intact PTH.” Not all serum c-PTH levels were significantly correlated with serum Ca, P or the Ca×P product. A non-significant negative correlation existed between the ionized Ca and PTH levels (0.1<p<0.2). The serum levels of c-PTH decreased gradually in accordance with improvements of hypocalcemia and hyperphosphatemia in 10 out of 11 cases once regular dialysis started with supplementary therapies (aluminium hydroxide, Ca carbonate, active vitamin D, etc.) In one of the 11 cases with high c-PTH, the initial c-PTH was extremely high, 23.6ng/ml, and cervical CT and scintigram revealed enlarged parathyroid glands. However, both tests decreased gradually and progressively. On the other hand, one out of the 11 cases, placed under CAPD did not respond to various therapies and still shows serum c-PTH levels of over 10ng/ml even after two years. Generally dialysis patients with high serum levels of c-PTH respond to various therapies much better in the initiation period than long-term dialysis patients do. In summary, abnormal Ca, P and PTH metabolism develop in early renal failure. They are not problems of long-term dialysis patients only. They must be carefully and vigorously managed during the early course of chronic renal failure. A routine measurement of biologically active “intact PTH” is also mandatory in order to approach secondary hyperparathyroidism and renal osteodystrophy more precisely.

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Twenty-four-hour electrocardiographic monitoring (Holter ECG) and echocardiographic studies were performed in 185 patients including 100 patients on maintenance hemodialysis (HD) and 26 patients on continuous ambulatory peritoneal dialysis (CAPD). Electrocardiographic monitoring revealed atrial premature contraction (APC) in 87 HD patients (87%) and ventricular premature contraction (VPC) in 58 HD patients (58%). Twenty-two HD patients (22%) showed more than 100 APC beats/day and potentially hazardous VPC such as Lown's grade 3-5 were observed in 26 HD patients (26%). VPC tends to be more frequently influenced by hemodialysis per se in comparison with APC. The age, left ventricular dimension and ejection fraction in HD patients with frequent APC were significantly different from those in patients without APC. The left ventricular dimension and left ventricular wall thickness were significantly increased in HD patients with frequent VPC, as compared with those in patients without VPC. Bradycardial atrial fibrillation was the most frequent type of bradycardial rhythm disturbance. Advanced AV block was the major reason for permanent pacemaker (PM) implantation in HD patients before initiation of HD, while sick sinus syndrome was the main reason for PM implantation after initiation of HD. Although it seemed very difficult to place sufficient load on HD patients in exercise testing and some problems still remain with regard to evaluation of the results, exercise testing showed no sign of ischemia in HD patients who developed VPC during HD without apparent heart disease.

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