Infection is one of the common complications seen in hemodialysis patients and may prove fatal.
We report a case of liver abscess complicating hemodialysis.
A 28-year-old man had been receiving maintenance hemodialysis from June, 1986. After six months, the patient was admitted to our hospital for dyspnea and high fever. Abdominal echotomography and CT showed an abscess (90×80mm) at S₂ in the left hepatic lobe. Intravenous antibiotic treatment was started and US guided abscess drainage was performed. Two months after drainage, fistulography showed no alteration attributable to abscess. The drainage tube was removed and the patient, who showed clinical improvement without antibiotic treatment, was discharged.

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The number of diseases requiring maintenance hemodialysis has lately increased along with the number of patients.
Consequently, long-term survival has been steadily increasing. As the result issues, blood access-related problems have become one of the most important in hemodialysis therapy.
In the years 1984 through 1986, 115 surgical procedures were carried out at our institution to repair nonfunctioning or poorly functioning blood accesses in 105 patients.
Most of such patients were female and the peaks of repair surgery occurred during 1-2 years and from 7 years after hemodialysis initiation.
Early failure of the access was considered most likely to be due to poor condition of vessels. Even though vessels might be satisfactory for the establishment of initial blood access, vessels especially veins are-gradually damaged by continuous pressure load on arterialized veins and also by frequent puncture.
Ectopic calcification is most frequently seen in vascular walls, which also damages the vessels and causes poor blood flow and/or thrombosis; surgery to establish a vascular access may therefore be difficult.
The condition of internal AV-fistula must be evaluated in each hemodialysis procedure from findings of inspection and palpation, puncturability, obtainable blood flow and venous pressure.
Simple X-P, echo, fistulography and thermography must be undertaken thoroughly without delay if necessary; these approaches yield a lot of information for repair surgery.
Poor or decreased fistula flow due to venous sclerosis and or stenosis was the most common reason for repair surgery in this series and thrombosis due to the same cause ranked next.
In 7 out of 115 operations, only superficialization of the arteries was possible; 6 out of 7 cases were transferred to CAPD thereafter.
A graft (Gore-Tex) was used in 24 cases (20.8%). In the remaining cases repair or re-anastomosis was possible proximal to the initial AV-fistula. Techniques for repair or re-anastomosis are apt to vary because of the wide range of causes and degree of access-related problems.
The following considerations are mandatory for blood access-related surgery: (1) Is repair technically possible? (2) Is an artificial graft necessary? (3) Will repair facilitate further long-term use? (4) Will repair create new problems? (5) Will puncture be possible 1-2 days after surgery?
Early diagnosis and prompt treatment considering the above-mentioned factors can prolong blood access patency.

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In order to evaluate biocompatibility in hemodialysis, we measured three parameters; whole-blood activated coagulation time, APTT and fibrinopeptide A concentration determined by enzyme immunoassay in the extracorporeal circuit. Studies were performed on ten maintenance dialysis patients during a 4-h dialysis session, using two kinds of anticoagulant; heparin and synthetic antithrombin (MD 805). The effectiveness of anticoagulation was assessed by determination of fibrinopeptide A (FPA), which is a useful marker of thrombin activity on fibrinogen conversion. There was a linear correlation between FPA production in the dialyzer and the FPA concentration of blood in the arterial line to the dialyzer in both anticoagulant sessions. Higher production of FPA was noted at 60min after the start of hemodialysis when continuous infusion at 0.3mg/kg/h of MD 805 was employed. Although the anticoagulant activity was essentially the same for the two anticoagulants, the discrepancy in FPA production between the two anticoagulants was thought to be because of their different interaction on the artificial membrane. The biocompatibility of the extracorporeal circuit by determination of FPA production may be influenced by pharmacological characteristics preventing thrombus formation on the artificial membrane in addition to anticoagulant action within blood vessels.

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A total of 58 bone biopsies were performed in 54 patients undergoing long-term dialysis, and their renal osteodystrophy was classified on the basis of clinical and biochemical findings, bone X-ray, bone scintigram, histology and effects of PTX or DFO therapies.
Histologically, the biopsy cases were classified into osteitis fibrosa (20), mild bone disease (9), osteomalacia (6), aplastic bone disease (21), a mixed type of osteitis fibrosa and osteomalacia (1), and osteoporosis (1). On the basis of scintigrams, the cases were classified into the patterns of osteitis fibrosa (19), osteomalacia (6), aplastic bone disease (18), and non-specific lesions (9).
The accordance rate for both classifications was 100% for osteomalacia and aplastic bone disease, and 84.2% for osteitis fibrosa. Of non-specific lasions, 88.9% were mild bone disease histologically. Aluminum-associated osteopathy was observed in 46.6% of cases: histologically, 71.4% of cases were classified as aplastic bone disease, 100% as osteomalacia, 55.6% as mild bone disease, 100% as mixed type, and none as osteitis fibrasa or osteoporosis. The pain-releiving effect of PTX or DFO therapy was marked in the lumbar ragion and hip joint and slight to moderate in the knee and ankle joints, but no effect was observed in the shoulder and hand joints. DFO was not effective in aluminum-accumulation disease. The histological effects of DFO evaluated in 8 cases revealed improvement or disapperance of Al staining, decreased osteoid, and increased active formation and absorption surfaces.
Based on these results, the 58 cases were classified into: group 1) osteitis fibrosa (active vitamin D or PTX effective), 2) aluminum-associated bone disease (DFO effective), 3) amyloid-associated osteo-arthropathy, and 4) non-aluminum-associated non-amyloid-associated (no underlying etiology was found).

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Among the various forms of blood purification therapy available today, HDF seems to be one of the best methods for removal of both uremic solutes (small, middle and large molecular-weight substances) and fluid overload in the shortest possible time.
With regard to hardwear, on-line high-flux HDF (hard HDF), in which a large volume of substitution fluid was supplied from the bicarbonate dialysate by ultrafiltration, was clinically tried.
With ragard to softwear, so-called biofiltration, in which a small amount of hypertonic bicarbonate solution was applied as a substitution fluid, was tried for shortening of the treatment period.
Six patients on hard HDF and 8 patients on soft HDF were entered into a clinical study in which dialysis time was shortened by one hour in comparison with the control HD period. In both methods, a high-performance membrane was used as a high-flux hemodiafilter.
In hard HDF, no problems were encountered in the removal of both solute and fluid overload and correction of uremic acidosis. PTH level was decreased in one patient, and alumigel dose could be reduced in 3 patients. Total elimination of β₂-MG per session rose from 150mg to 300mg, and the reduction rate was calculated to be 50-70%. The β₂-MG maintenance concentration could be lowered by 20-30%, i.e., by more than 10mg/l. With the use of a biocompatible hemodiafilter, good long-term clinical results could be expected.
In soft HDF, the reduction rate of small molecules decreased, so that the plasma phosphate level increased, resulting in a higher PTH concentration in 3 patients. In 5 patients, excessive alkalosis was found.
Conclusion: Hardwear for short-term dialysis consists of high blood flow, bicarbonate dialysate or substitution fluid and a precisely controlled ultrafiltration system. For sufficient removal of large molecules such as β₂-MG, hard HDF with increased convective flow should be applied. With higher blood flow and a more permeable membrane, ultra-short dialysis of less than 3h might be possible. In soft HDF, insufficient solute removal and over-correction of acidosis remain the main problems, and improvements need to be made in the softwear itself.

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During the last nine years, a total of 2, 595 blood access operations were performed. The majority, i.e. 1, 472 cases, were operated for reconstruction. Another 258 cases involved grafts.
The most predominant manifested indication for the operation was stenosis of blood vessels with either internal or external shunts, of which there were 1, 737 cases. The operation for 974 cases was completed in less than 60min. with an average time of 55.2min. If only external shunt is considered, 510 cases were completed in less than 30min. The overall average operation time was 43.3min.
In elderly patients, long termed hemodialysis patients and patients who have complication of diabetic mellitus or SLE, the following points should be kept in mind: Before the operation, the patients should be washed and scrubbed in the same manner as the surgeon. With regard to external shunt, certain preparations should be performed with the vessel tip and the suture fixing body tube, etc. The operation time and amount of bleeding should be kept to a minimum.
For this purpose, the surgical team should consist of a surgeon who is specialized in shunting and an experienced and well trained staff. In addition, utilization of easily infected and poor quality artificial vessels should be avoided. Infection can be prevented with antibiotic therapy together with the cooling down and swabbing of the affected area. Furthermore, with regard to the characteristic obstruction of blood access, declotting should be properly conducted. In particular with external shunt not only a Fogarty but also a bronchofiber brush should be used to eliminate coagula.
To prevent formation of thrombi, anticoagulant therapy should be administered, and if a thrombus is formed, early detection and subsequent treatment is essential. In addition, education of patients and staff, daily management of blood access, promotion of vessel enlargement by exercising and a detailed surgical record by the surgical team are important for the long term maintenance of blood access.

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Recently, it has been increasingly recognized that long-term hemodialysis (HD) patients have complicating amyloid osteoarthropathy and that cystic radiolucency is observed in the affected joints. In order to clarify the relationship between the cystic bone lesions and amyloid osteoarthropathy in HD patients, we studied the cystic radioluceny of the wrist joints and their correlation with clinical and laboratory parameters in 376 HD patients. The cystic radiolucency was classified into four grades: (-), (±), (+) and (++). Cystic lesions were noticed in 86 patients (22.9%), in which there was no sex-related difference in the incidence of positive cystic lesions. The incidence was 33.0% among 103 patients who had received long-term HD for more than 10 years compared with 19.0% among 273 patients on HD for less than 10 years. Cystic lesions were also seen in 68.4% among 19 patients with carpal tunnel syndrome (CTS) compared with 20.4% among 357 patients without CTS. Patients with higher cystic grades were older, and had been receiving hemodialysis for longer periods. There was no relationship between the grades of cystic lesions and serum levels of PTH-C, aluminum or β₂-microglobulin. Biopsy specimens of bone cysts in two patients demonstrated amyloid deposits, which showed an immunohistochemically positive reaction with rabbit antihuman β₂-microglobulin antibody. It is suggested that cystic raiolucency in the wrist joints of HD patients is indicative of amyloid deposition and that it could be a useful marker for the diagnosis of amyloid osteoarthropathy.

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Hemodynamic states in short-time dialysis were evaluated in 7 dialysis patients by means of a Swan-Ganz thermodilution catheter. Seven patients were treated with 3 hours hemodialysis (3hHD) with a large-surface-area dialyzer (n=4) or 4hrHD with a small-surface-area dialyzer (n=3), and with 3-h hemodiafiltration (HDF) or 4hHDF. Hemodynamic parameters, biochemical data, electrocardiography, chest X-ray films, echocardiography, and total body water by the use of deuterium oxide were compared for each dialysis treatment. There was no significant difference between 3hHD and 4hHD with regard to hemodynamic parameters, biochemical data, and so on. The same results were obtained for 3hHDF and 4hHDF. Hemodynamic stability thus depends not on dialysis treatment time but on volume removal. It is thus important to manage the degree of weight gain in order to control hemodynamic stability in short-time dialysis.

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Carpal tunnel syndrome, which was first described by Paget in 1853, has been frequently found in chronic hemodialysis patients. Furthermore, amyloid protein and β₂-microglobulin are considered to be implicated in the cause. There have been many reports that amyloid protein and β₂-MG deposits are found not only on transverse ligaments but also on various organs in the body. By May 1987, 165 dialysis patients with this syndrome had visited our kidney center, and 187 hands had been operated on. In one of these patients bilateral tumors on the hip joints developed and tumorectomy was performed. Autopsies were performed on 29 patients that died in the course of renal failure during hemodialysis therapy, (21 with acute renal failure and 8 with chronic reral failure). At each operation or autopsy, a specimen was taken for pathological examination. Specific findings of the operated cases were staining for congo red, arteriosclerosis, membranous lipodystrophy and hyalinosis. Other findings were infiltration of inflammatory cells, hyperkeratosis of skin and an increased number of monocytes in the synovial membrane. In autopsy cases, we found positive staining for congo red and β₂-MG around the arteriolae in the cardiac muscle and rectal mucosa and in the microcysts in the kidney in two cases.
The level of serum β₂-MG in the patients with hemodialysis amyloidosis was not significantly higher than those without hemodialysis amyloidosis.
Because of the variety of pathological findings, further pathological and biochemical investigations will be needed.

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