A study was performed in order to compare Ca metabolism in acetate dialysate (Ca⁺⁺ 3.0mEq/l) and bicarbonate dialysate (Ca⁺⁺ 3.0mEq/l) in hemodialysis patiente.
In bicarbonate dialysate, plasma levels were Ca⁺⁺ 2.2±0.3mEq/l, Mg 2.8±0.4mg/dl and Al 45±26μg/l, which were lower than in acetate dialysate, while the level of P, 6.1±5.4mg/dl, was higher. However, C-PTH a significant increase during hemodialysis.
In patients who had begun hemodialysis treatment using acetatl or bicarbormte dialysate 6 months previously, a significant decrease in C-PTH was found in bicarbonate dialysate: C-PTH level in bicarbonate dialysate was 42.3±3.4% of the initial value, and 85.5±38.7% in acetate dialysate. On the other hand, there were no differences in the changes of Ca and P between bicarbonate dialysate and acetate dialysate.
Bone mineral contents in bicarbonate dialysate were lower than in acetate dialysate after 2 years: decreases were found in MCI (MD method) in 4/12 cases (33.3%), ΣGS/D in 9/12 cases (75.0%) and BMC/BW in 6/12 cases (50.0%).
The decrease in C-PTH was more marked in bicarbonate dialysate than in acetate dialysate, implying that bicarbonate supresses PTH secretion.
Low serum PTH, low turnover bone, severely increased acidosis, and a decrease of bone mineral contents may frequently occur in bicarbonate dialysate.

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Blood pressure changes before and after renal transplantation and the factors contributing to them were studied in 72 living-related allograft recipients with a follow-up of 3 years.
Of patients on 3-times-a-week, in-hospital dialysis, 30 (42%) had hypertension and 8 (11%) hypotension. After renal transplantation, 48 (67%) developed hypertension in 3 years. The hypertensives on dialysis tended to remain so, in spite of successful renal transplantation. The incidence of hypertension was higher in those with 2 or more acute rejection episodes than in those with none or one. Twenty-one patients developed chronic rejection, and all but 3 had hypertension.
After renal transplantation, plasma renin activity (PRA) of the hypertensives was higher than that of the normotensives. Split renal vein renin activity was measured in several patients. In all, PRA from the original diseased kidneys was higher than that of the graft. Renovascular hypertension due to graft artery stenosis was seen in only one patient who required by-pass surgery.
Two-thirds of the postoperative hypertensives were well controlled with one or two anti-hypertensive drugs.
Eight patients showed hypotension on dialysis, 4 of whom had undergone bilateral nephrectomy mainly because of small renal cell carcinoma complicated with acquired cystic disease of the kidney.
Despite the development of oliguric acute renal failure in 5 of 8 patients after surgery, blood pressure returned to the normal level soon after transplantation in all patients. This process was far quicker than the recovery of uremic neuropathy, suggesting that some humoral factor (s) from the normal kiney tissue was involved.

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Almost all recent hemodialysis machines are computerized, making operation easier in mary. Features that will be required in future computerized hemodialysis machines were investigated by examining safety control in computer systems used in present conventional hemodialysis machines. It was found that further improvelemt of computerized safety control will be unlikely if it is based on present patient monitoring machines. Standard protocols communicating data between computer and hemodialysis machines will be needed, as will hard-and software that allows combinations and control of hemodialysis systems. This will enable improved safety control of the entire system through effective information processing by computer. Furthermore, computer knowledge will be required to operate future hemodialysis machines.

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Between April 1982 and March 1987, 256 external shunts were inserted and 190 internal shunts were created in our Department of Renal Diseases. Of these 256, 83 patients are still in hospital and arteriovenous fistulas have been constructed in 50 of them using the dilated vessels of previous external shunts. The reoperation rate after conversion to internal shunt was 18% (9/50). This compares favorably, in long-term results, with the reoperation rate of 37% (31/84) for 84 patients (still in this hospital) of 190 with the successful creation of an internal arteriovenous shunt.
In patients with acute renal failure or sudden aggravation of chronic renal failure and in cases of narrow cutaneous vein, we make it a rule to first construct an external shunt and convert it to an internal shunt after the vein has dilated.
This procedure does not require a temporary blood access and offers the additional advantages of free movement to the patient as well as ease of management. Moreover, in cases who present a devastated cutaneous vein at shunt operation, those in which an extensive shunt infection makes it difficult to construct a bypass, those in which the proximal side of the internal shunt has been totally obstructed, and even those which call for E-PTFE graft (Gore Tex^®) but do not permit an immediate puncture, we often construct a Gore Tex^® externan shunt in the first place and, after puncture has become feasible, convert it to an internal shunt. Thus, during the 5-year period mentioned above, a Gore Tex^® external shunt was constructed in 76 cases. The Gore Tex^® external shunt is useful for patients whose increased blood coagulation or hypotension would cause frequent clotting of the Gore Tex^® internal shunt. The external shunt dispenses with the declotting operation and contributes to a decreased overall frequency of operation. There are six such patients in this hospital. We also made a special prototype connector on an experimental basis and have been using it to connect the Gore Tex^® graft to an external shunt. Results have been satisfactory. Shunt infection, which is often a problem with external shunts, is rare in this hospital and the operation for external shunt infection has been performed in only 5 cases during the 5-year period. Thus, the external shunt offers several advantages which cannot be overlooked even in light of the modern trend toward internal shunts.

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Twelve patients with end-stage renal disease underwent heart operation: aorto-coronary bypass graft (ACB) in five, resection of ventricular aneurysm and the closure of septal penetrance in one, valvular replacement in two, mitral commissurotomy in two and the patch closure of atrial and/or ventricular septal defect in two. Before operation, 8 patients were maintained on hemodialysis (HD), while 4 were maintained on continuous ambulatory peritoneal dialysis (CAPD). The duration of the treatment with HD and/or PD before operation ranged from one month to III months (mean 21.8±32.3). After the operation, two patients were maintained on HD, 5 on intermittent PD (IPD) and the remaining 5 on continuous PD (CPD). During the operation, both HD and hemofiltration were performed in combination with cardio-pulmonary bypass (CPB) to control the water, electrolyte and acid-base balance and to eliminate uremic toxins. Out of 12 patients, two died of sepsis on 15 POD and low-output syndrome on 1 POD, respectively (operative death: 16.7%). In seven patients out of 10, HD was substituted for PD, and two of them died of cerebellar and gastrointestinal beeeding on 35 POD and hemorrhagic brain infarction on 51 POD, respectively. In four patients who were treated with CAPD both before and after operation, the postoperative course was very satisfactory. CAPD is considered to be a promising therapeutic modality. Additionally, intraoperative hemodialysis and hemofiltration in combination with CPB is very effective for the control of water, electrolyte and acid-base balance and the prevention of azotemia.

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Purpose.
In recent years, the incidence of colo-rectal cancer has increased and elevated lesions of the colon and rectum have often been found in hemodialysis patients. As a screening test for colo-rectal cancer in hemodialysis patients, we applied the passive hemagglutination method which is specific to human hemoglobin.
Subjects and Methods.
Two-hundred thirty hemodialysis patients over the age of 30 years at Kojin-kai Central Hospital were studied. RPHA was performed twice on the patients who had no dietary restrictions, Examination of the lower digestive tract was conducted on those patients in whom RPHA was positive. The conventional chemical test for fecal occult blood was carried out together with RPHA.
Results
Thirty-one patients (13%) were positive in the first RPHA examination and 35 (15%) in the second one; 50 patients (21%) eventually showed positive. Thirty-one of the 50 patients were further examined. Twenty-nine lesions were found in 19 patients (one early cancer in one, 24 adenomas in 16 and four non-identifiable tissues in two). In six patients both of two RPHAs were positive, while in the remaining 13, one of two was positive. The positive rate by the conventional fecal blood test accounted for over 50% of the patients studied, suggesting that a substantial number of false-positive results due to food or drugs may be included.
Conclusions
RPHA is more reliable for the screening of colo-rectal lesions in hemodialysis patients than the conventional chemical method. Lesions were found mostly in patients on longterm hemodialysis. Therefore, RPHA, which is specific to human hemoglobin and available without dietary restrictions, is beneficial to the screening of colo-rectal lesions in hemodialysis patients. Since there are some patients who were positive only one of two RPHAs. repeated measurements are necessary.

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Twenty cases (2.5%) of aortic aneurysms (AA) in 805 patients with chronic renal failure have been experienced in our institution during the past 12 years. Nine hemodialysis patients with AA were included. The average age of the 20 patients was 66.8 years, and they consisted of 14 males and six females, pain in the respective regions was the most common clinical symptom (65%). Seven cases revealed thoracic AA, 10 abdominal AA and three thoraco-abdominal AA. The pathogenesis in nine cases was arteriosclerotic, dissecting in six and unknown in six.
The 20 cases were subdivided into four groups based on hemodialysis (HD) and/or operation for AA (OP) as follows: Group I (n=9): HD (-), OP (-), Group II (n=5): HD (+), OP (-), Group III (n=2): HD (-), OP (+), Group IV (n=4): HD (+), OP (+). The average age of the respective groups increased in the order of I>IV>III>II and the average size of AA increased in the order III>IV>II>I. A woven Dacron graft replacement and aortic wrapping were used in most operated cases, and hemodialysis incorporated to V-A bypass was adopted as an additional procedure in two cases of thoracic AA. The amounts of bleeding, fluid and blood transfusion were much greater in Group IV than in Group III; however, the average duration until discharge after AA operation was shorter in Group IV. Other complications besides AA included hypertesion in 85% and cardiopulmonary lesions in 80%. Four of 20 patients are alive, whereas 16 (80%) have died. All patients in Group I died and three in Group II died due to the rupture of AA. One of two patients in Group III and one of four in Group IV are still alive after operation for AA. One of the three dead patients in Group IV died after two years.
Nine operated cases of AA in hemodialysis patients have been reported in the Japanese literature. According to our study of these cases and actual patients, aggressive operation with discrete preparation is indicated for AA in hemodialysis patients as increasing numbers of patients with this serious complication are anticipated in the near future with the expansion of the hemodialysis population.

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A total of 263 patients were treated with chronic hemodialysis (HD group), the diagnosed disease being chronic glomerulonephritis in 204 cases, diabetic nephropathy in 12, pregnancy-related kidney disease in 12, polycystic kidneys in 7, chronic pyelonephritis in 7, nephrosclerosis in 6 and other diseases in 15. The control groups were 78 healthy volunteers (Coat group) and 160 diabetic patients (DM group). Autonomic nervous system disturbance was examined using the coefficent of variation of the R-R interval in ECG (referred to as CV below), as was the possible relationship of CV to variation in blood pressure (BP) and pulse rate during hemodialysis. The mean CV in the HD group was 2.2±1.0%. CV tended to decrease as age increased in all groups, decreasing in the order Cont group>DM group>HD group in all age groups examined. The downward trend of CV with increasing age was remarkable when the duration of hemodialysis was short; however, no constant trend was observed between hemodialysis duration and CV by age distribution. Mean CV varied according to disease. For chronic glomerulonephritis, the mean CV was 2.3±1.0%, close to the HD group mean. For diabetic nephropathy and nephrosclerosis, it was 1.2±0.6% and 1.4±0.4% respectively, both significantly lower than the overall mean value. On the other hand, the mean CV tended to be high for polycystic kidneys: 2.7±1.3%. Although hemodialysis-induced hypotension is said to be accompanied by autonomic nervous system dysfunction, the differences between the maximum and minimum values of systolic BP, diastolic BP and pulse rate were confirmed to have no correlation with CV in the present study.

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