Various clinical laboratory data regarding arterial blood pressure were analyzed, and autonomic nerve function test by Valsalvas maneuver was done on 13 maintenance hemodialysis patients with persistent hypotension.
We failed to find significant low values in either plasma renin activity or plasma concentration of noradrenalin in patients with this complication.
On the other hand, the Valsalva index indicated a significantly lower value (1.24±0.15 v 1.43±0.18) and clear negative correlation with plasma concentration of noradorenalin, (r=-0.56). Therefore, it is strongly suggested that an autonomic nerve dysfunction mediated by a baroreceptor is implicated in the pathogenesis of this complication, and the “down regulation” mechanism may be operating in the background of its development.
In addition, sodium concentration in erythrocytes was measured and a significantly low value was found in patients with this complication (11.5±1.5 v 13.3±2.6, 14.0±2.9mEq/l).

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A total of 188 long-term hemodialysis patients surviving more than 10 years were clinically analyzed in Kyoto Prefecture, and their quality of life and general aspects of their complications were investigated. The rate of patients surviving more than 10 years compard with all hemodialysis patients in Kyoto Prefecture was 13.1%, slightly higher than the average in Japan (10.6%), because chronic hemodialysis was applied here earlier than in other areas.
The average age of subjects was 48 years, and 60.6% were male and 39.4%, female. The primary reasons for these patients to be on dialysis were as follows: chronic glomerulonephritis (71.8%), nephrosis (5.3%), chronic pyelonephritis (2.1%) and tuberculosis (2.1%). They included 183 outpatients and 5 hospital patients. Main complaints were joint pain (23.4%), dyskinesia (7.4%), paralysis (5.3%) and lumbago (4.3%) probably due to renal osteodystrophy and dialysis associated amyloidosis.
Physical and laboratory findings of these patients were as follows: mean TP 6.6g/dl, mean Ht 26.7%, mean BUN 80mg/dl and mean Cr 12.7mg/dl. Almost all patients hope to have the stress of dialysis treatment reduced however, they seem to be reasonably satisfied with their treatment from the fact that only 10.1% of them hope to have renal transplantation. There was difference in the evaluation of quality of life between patients (20.2%) and doctors (5.9%). The present analysis suggests that it is important to pay careful attention to renal osteodystrophy and dialysis associated amyloidosis.

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To improve methods for evaluating autonomic functions in uremic patients undergoing hemodialysis, autonomic functions were studied in 12 diabetic patients, 14 non-diabetic patients and 12 normal controls. Blood pressure and heart rate responses while standing, during the Valsalva maneuver and while sustaining firm handgrip were measured, and the spectral analysis of beat-to-beat fluctuations in heart rate and microvibration, and peripheral blood flow analysis were made in all patients and controls.
The classical methods (measurement of blood pressure and heart rate responses) revealed that the dialyzed patients, especially the diabetic group, had autonomic dysfunction. However, the stimuli used in these tests such as holding the breath, standing, and gripping were aggravating to some patients and the degree of stimulus varied in each patient. Therefore, a nonaggravating, quantitative method to assess autonomic control must be established.
The spectral analysis of heart rate and microvibration, and peripheral blood flow analysis are cited as acceptable alternative methods for this purpose. In this study, however, the power spectrum of the heart rate using the maximum entropy method did not reveal any differences between dialyzed patients and controls. In the spectral analysis of microvibration using a fast Fourier transform, ation an abnormal pattern was observed in 25% of dialyzed patients. The peripheral blood flow measured by laser doppler flowmeter was reduced in patients receiving hemodialysis. However, the results did not correlate with results obtained by the classical methods, because the reduction of blood flow was also attributable to abnormalities of both nerve and vessel.
Therefore, it is concluded that the classical methods are still the most useful at the present time. Further development to analyze the heart rate interval or microvibration will be necessary to establish alternative useful methods for measuring autonomic function.

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The clinical insulin requirement of diabetic patients changes after they develop renal dysfunction or start hemodialysis (HD). Therefore, an index of endogenous insulin secretion for such patients is needed in the management.
Plasma C-peptide immunoreactivity (CPR) is a likely laboratory index, but it has not been clinically useful for patients with chronic renal failure, because degradation of C-peptide is much impaired and modulated in these patients.
However retention of C-peptide is almost the same in the final stage of renal failure because there is no more urinary excretion of C-peptide: Thus the plasma level of CPR may depend on the degree of insulin secretion in HD patients.
To evaluate the usefulness of plasma CPR measurement in patients with diabetes mellitus (DM) under HD, we selected 46 patients and divided them into three groups for this study. Group A consisted of six patients with insulin-dependent DM, group B 18 patients with non-insulin-dependent DM, and group C 22 non-DM patients. All subjects were undergoing regular HD.
The mean fasting plasma CPR level in group A was significantly lower than that in the other groups (p<0.001). Also, this level in group B was significantly lower than that in group C (p<0.01). When plasma CPR was measured during the 50g oral glucose tolerance test, the mean plasma CPR rose significantly in group C (p<0.01), but not in the other groups. The mean plasma CPR was lower after glucose loading in the patients in group B who were treated with insulin than in those in the same group who were not treated with insulin. There was negative correlation between insulin requirement and the fasting plasma CPR level in the patients treated with insulin (r=-0.63, p<0.05).
The level of fasting plasma CPR was correlated to the endogenous insulin secretion in our subjects with DM who were on HD. These results suggest that the plasma level of CPR is a clinically useful index of insulin secretion in such patients.

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The removal rate of inorganic phosphate in 75 chronic hemodialysis patients was calculated to be 52.3±9.98% (mean±SD, n=75) by sampling blood of the pre- and postdialytic period. The removal rate showed no positive correlation with total dialyzed blood volume, which was estimated by blood flow rate (ml/min) × surface area of dialyzer (m²). There were no significant differences in phosphorus removal rate between various membranes such as Cuprophan^®, EVAL, PAN and cellulose acetate. However, the higher predialytic serum inorganic phosphate showed a significantly higher removal rate. Mass removal of phosphorus was measured in six patients who were dialyzed for 5 hours with Rhodial 75 (recirculating dialysate-supplying system) and an H 12 2400 dialyzer (PAN, 1.0m²). The value ranged widely from 540 to 1500mg/treatment and the mass removal was larger in cases with a higher predialytic serum inorganic phosphate level.
The dietary intake of phosphorus was calculated in 50 patients, and was revealed to be 982±192mg/day (mean±SD, n=50). Restriction of dietary phosphate intake was, thus, not fully satisfactory in our center and the proportion of patients with a predialytic serum P level of more than ranged 5.5mg/dl was from 30 to 65% monthly.
Inorganic phosphate output of anuric chronic hemodialysis patients was estimated to be about 830mg/day (renal=0, HD=1, 000mg, fecal=400mg/day).
Consequently, the principle means of preventing phosphate retention and hyperphosphatemia include appropriate restriction of dietary phosphate intake (less than 830mg/day) and use of phosphate binding agents.
Mass removal of inorganic phosphate should be measured precisely with each therapeutic modality for each membrane, since inorganic phosphate removal by blood purification methods is the most important factor to handle in chronic hemodialysis patients.

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We investigated cell-mediated immunity in dialysis patients. The data indicated that dialysis patients have lymphopenia, decreased reaction of PPD and decreased blastoid formation of PHA.
PPD reaction and T-cell function decreased in the early stage of dialysis and improved in the stage of maintenance dialysis, then subsequently decreased again in the long-term stage of dialysis.
These data suggests that patiens on dialysis have decreased immunologic host defense in the early and long-term stages of dialysis.

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Infection is one of the common complications in dialysis patients, but cerebrospinal infections are relatively rare.
The present report records the first two cases of meningitis due to Klebsiella (K) pneumoniae in hemodialysis patients in Japan.
Case 1: A 36-year-old female was admitted for disturbance of conciousness eight years after beginning hemodialysis. Physical examination on admission revealed stupor and stiffness of the neck. In a direct smear of the CSF, Gram-negative bacilli were seen and the micro-organism was identified as K. pneumoniae. The patient received chemotherapy. She died three days after admission. Autopsy findings revealed meningitis due to K. pneumoniae.
Case 2: A 51-year-old female was admitted for disturbance of conciousness and high fever 7.5 years after beginning hemodialysis. Physical examination on admission revealed coma, fever of 40.7°C and 66mmHg in systolic blood pressure. She died 13 hours after admission. Autopsy findings revealed meningitis due to K. pneumoniae.
Since the incidence of attack by an opportunistic pathogen such as K. pneumoniae is always greater in compromised hosts such as dialysis patients, attention must be paid to the occurrence of opportunistic infections.

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In long-term hemodialyzed patients, acquired cystic disease of the kindney (ACDK) has been followed not only for the occurrence of renal tumor but also for the improvement of anemia. Neverthless, there are few reports on the correlation between ACDK and anemia. In this study, we examined kidney volume, renal cyst formation, duration of hemodialysis, and hematocrit (Ht) level in chronic hemodialysis patients. The underlying diseases were chronic glomerulonephritis (CGN) and diabetic nephropathy (DMNP).
In 53 hemodialyzed patients (CGN 35, DMNP 18), kidney volume and renal cystic formation were measured by renal computed tomography. Mean duration of hemodialysis was 6.3 years in the CGN group and 3.1 years in the DMNP group.
In the CGN group, both kidney volume and Ht level increased significantly with the duration of hemodialysis (y=6.33x+51.9, γ=0.50, P<0.005 and y=0.87x+18.1, γ=0.60, P<0.001, respectively). The number of patients with ACDK also increased with the duration of hemodialysis. All 7 patients on more than 10 years of hemodialysis were associated with ACDK. On the other hand, in the DMNP group, kidney volume decreased significantly with the duration of hemodialysis. Ht level was not changed. Renal cystic formation was observed in only 3 patients in the DMNP group and there were no patients associated with multiple cysts. In the CGN group, the Ht level of patients with renal cyst was significantly higher than that of patients without cyst. On the other hand, in the DMNP group, there was no significant correlation between cyst formatiom and Ht level.
In conclusion, there were marked differences between the CGN and DMNP groups, in kidney volume, percentage of cyst formation, and improvement in anemia. The results suggest that cystic formation in atrophic kidney might play an important role in improving renal anemia in longterm hemodialyzed patients.

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In 71 patients on regular hemodialysis, the serum concentration of aluminium (Al), the variation in serum concentration of Al after Desferrioxamine (DFO) loading (ΔAl), and erythrocyte Al (RBC-Al) were measured and Al accumulation was evaluated.
ΔAl at 15mg/kg of DFO indicatad a significant positive correlation with the duration of hemodialysis (r=0.51), and a remarkably higher value of ΔAl more than 150μg/l, was recognized in 12 of 15 cases with an HD history of more than 108 months.
In addition, although ΔAl at 7.5mg/kg of DFO showed a clear correlation with the ΔAl at 15mg/kg of DFO, only one of 14 cases showed ΔAl at 7.5mg/kg of DFO higher than 150μg/l.
On the other hand, neither the serum concentration of Al nor RBC-Al was correlated with the duration of hemodialysis.
We concluded that, in evaluating Al accumulation in long-term HD patients, estimation of ΔAl at 15mg/kg DFO seems to be the best method.

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The technique of plasma pheresis has been applied to a number of immune disorders. The serum of patients with pemphigus vulgaris contains an antibody (usually IgG) directed against an antigen in the epidermal intercellular space. There is some evidence that the titer of this antibody, correlates with disease activity. Plasmapheresis, with its removal of the circulaing antibody, might be a useful adjunct to conventional treatment. We applied plasmapheresis to four patients with autoimmune skin diseases (one with pemphigus, one with bullous-pemphigoid, and two others with psoriatic arthropathy).
Plasmapheresis was perfomed with the double filtration membrane method. The plasma was substituted with 8% human albumin. We then continued plasmapheresis with a single membrane and substituted fresh frozen plasma.
The first patient, a 45-year-old man with pemphigus, required a large dose of predonisolone to control his disease during the ensuring several years. He developed steroid-induced cataract and steroid-induced diabetes. Gradually his disease became resistant to steroid therapy. Soon after we employed plasmapheresis, his skin lesions improved dramatically for two days but showed relapse. When we performed plasmapheresis again, using low-dose predonisolone and azathioprine, we could suppress relapse and control the disease. We did 13 treatments of plasmapheresis. The effect continued for more than three years. He is under continuing observation.
The second patient, a 24-year-old woman, suffered from bullous-pemphigoid and was medicated with predonisolone. She showed steroid-induced osteoporosis and steroid-induced muscle weakness. After 3 treatments of plasmapheresis, her skin lesions improved. However her skin lesions also relapsed. We tried three more treatments of plasmapheresis using low-dose predonisolone and azathioprine, and were able to control the skin manifestaions.
In the other two patients, who suffered from psoriatic arthropathy, plasmapheresis was also effective. They also showed relapse, but the relapse was suppressed by methotrexate. In psoriatic arthropathy, plasmapheresis seems to be more effective to arthropathy than skin manifestation.

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