In recent years, regular hemodialysis has been adapted to senile patients who have troublesome complications. Some of these senile patients lose their zest for living and complain of “suicidal despair.” We report the results of an analysis of factors involved in suicidal despair and an attempt to counteract this condition. Thirty patients (ages 18-78 years) who had been on dialysis for at least one year were studied. Five of 10 patients older than 65 years were found to have suicidal despair. Their physical condition was estimated from the hemodialysis score, number of complications, frequency of blood access operation and senile dementia. Their psychological condition was determined by manifest, anxiety score (MAS) and egogram. Sociopsychological, economical and religious problems were investigated by a questionnaire on their social adjustment and specific consciousness as an inhabitant of Toyama Prefecture. Results were as follows: Some of the 10 patients older than 65 years showed deterioration of dementia. Complications and frequency of blood access operation were apt to increase. Further more all of them showed a social consciousness specific to Toyama Prefecture. That is, they tended to esteem productivity and labor, suppress self-expression to a great extent and judge themselves as social stragglers who could not take part in production. In addition, 3 of 5 patients with suicidal despair showed strong anxiety and borderline dementia. We attempted increase their comfort and reduce their suicidal despair by taking account of the specific consciousness. As a result, the hemodialysis score and anxiety improved in 4 of 5 patients and borderline dementia improved in 3 of 3 about 10 monthes later. Suicidal despair diminshed gradually.
In summary, we analyzed factors involved in suicidal despair, a common but serious complication in senile hemodialysis patients. To improve the condition, we took account of their specific consciousness as local inhabitants of Toyama Prefecture. It is suggested that nursing senile hemodialysis patients by taking note of their specific consciousness may be beneficial in improving senile dementia and suicidal despair.

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The effect of hemodialysis on cell-mediated immunity was investigated in 30 hemodialysis patients. Several parameters of cell-mediated immunity, such as natural killer (NK) activity, antibody dependent cell-mediated cytotoxicity (ADCC), concanavalin A-induced suppressor T cell function (Con A-Ts), autologous mixed lymphocyte reaction (AMLR) and analysis of lymphocyte subsets using monoclonal antibodies by fluorescence-activated cell sorter, were assessed in these patients.
The NK activities of NK cells and ADCC were significantly decreased in hemodialysis patients compared with normal subjects. Moreover, AMLR of whole T cells, Tγ cells and T non γ cells were significantly decreased in hemodialysis patients compared with normal subiects. However, the Con A-Ts in hemodialysis patients was normal.
Peripheral lymhocyte subsets were measured using monoclonal antibodies (OKT and Leu series). The percentage of Leu3a, OKM1, Leu11a, OKla1 and HLA-DR positive cells were significantly higher in the hemodialysis patients, whereas the percentage of Leu2a positive cells was significantly decreased. In contrast, there was not such a big difference in the percentage of OKT3, OKT4, OKT8, Leu4 and Leu7 positive cells between the two groups.
We also studied the influence of blood transfusion on cellular immunity in hemodialysis patients. A marked decrease in AMLR between Tγ and non T cells was observed in blood transfused patients.
Concerning other cellular immunological functions, no abnormal findings were observed in blood transfused patients.
These results indicate that hemodialysis patients may have defects in immunological surveillance for neoplasma, defense against viral infections and the self-recognition mechanism.

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To appraise energy and protein requirements in diabetic dialysis patients, changes in body weight and serum albumin level were studied for three months, and precise diet histories were taken in 20 hemodiysis patients (mean age 58.9±10.7 years) and 22 CAPD patients (mean age 62.3±9.0 years) with diabetes mellitus.
Most diabetic hemodiaysis patients whose daily energy intake was less than 27kcal/kg of standard body weight tended to have decreased body weight and serum albumin, while those whose intake was over 35kcal/kg showed increased body weight and tended to develop obesity. In diabetic CAPD patients whose daily energy intake (represented as dietary intake plus peritoneal absorption of glucose from CAPD dialysate) was less than 28-30kcal/kg, body weight and serum albumin level tended to decrease, while over 35kcal/kg, body weight gradually increased and obesity tended to develop in a short time.
Serum albumin levels and body weight were decreased in the diabetic dialysis patients whose daily protein intake was less than 0.9-1.1g/kg of standard body weight on hemodialysis and 0.7-1.2g/kg on CAPD. However, even in patients whose daily protein intake was over 1.4g/kg, serum albumin levels did not increase in hemodialysis or CAPD patients.
In patients with diabetic renal failure who had been well maintained and rehabilitated on dialysis therapy for over one year, the mean daily energy intake was 31±2.6kcal/kg on hemodialysis and 30±3.4kcal/kg (sum of diet and peritoneal glucose absorption) on CAPD. Mean daily protein intake in these patients was 1.23±0.14g/kg on hemodialysis and 1.18±0.20g/kg on CAPD.
These results suggest that in diabetic dialysis patients the optimal daily energy intake is 31-33kcal/kg of standard body weight on hemodialysis and 30-32kcal/kg (sum of diet and peritoneal glucose absorption) on CAPD, while optimal protein intake is 1.2-1.3g/kg of standard body weight on both hemodialysis and CAPD.

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The pharmacokinetics of D-penicillamine (D-PA) were studied in a patient with Wilson's disease who required regular hemodialysis.
Following a single oral dose of 500mg D-PA on a day without dialysis, the maximum serum concentration was obtained after 4 hours (2.0μg/ml) and D-PA was detected in the serum even after 24 hours (0.9μg/ml). Among the metabolites of D-PA, penicillamine-cystein disulfide (PC) was first found in the serum. Its maximum serum concentration was obtained at 4 hours (31.3μg/ml). PC was still detected in the serum after 24 hours (12.0μg/ml). Penicillamine disulfide (PP) and S-methyl penicillamine (PSMe) were found in the serum 2 and 6 hours following the administration, respectively. These serum levels were higher at 24 hours (3.9, 10.4μg/ml) than at 6 hours.
The same dose of D-PA was administered 2 hours before dialysis to study the results. D-PA and its metabolites were found to be dialyzable. D-PA dialysis clearance was 82.0ml/min, and 10.5% of the administered dose of D-PA was cleared as unchanged during 4 hours of dialysis. Further 57.7% of D-PA including its metabolites was cleared during 4 hours of dialysis. The protein binding capacity of D-PA was thought to be slight on because of its good dialysis clearance.
Based on its chelating ability, a single 500mg dose of D-PA given 2 hours before dialysis appears to be appropriate. Another one or two dialyses without D-PA administration is necessary to eliminate its metabolites.

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Studies were performed to measure total body water in normal subjects (control), nephrotic patients with or without edema, and hemodialysis patients by using deuterium oxide. Analysis was performed by gas chromatography in conjunction with the platinum catalyst method. The 99.8% deuterium oxide was intravenously administrated to controls and nephrotic and hemodialysis patients. It took three hours to reach equilibration in the body water pool whether edema was present or not. Total body water to body weight ratio (TBW/BW) in controls and nephrotic and hemodialysis patients were 61.2±1.2%, 71.3±3.7% (with edema), 60.9±6.4% (without edma), 64.5±6.9% (pre-HD), 62.6±6.6 (post-HD), respectively, TBW/BW of nephrotic patients with edema was significant greater than that of controls (p<0.01), nephrotic patients without edema (p<0.01), and post-hemodialysis patients (p<0.05). TBW/BW of hemodialysis patients tended to be overhydrated in comparison with controls. Urine samples may also be used to calculate total body water. It is useful to determine TBW by using deuterium oxide for the management of body fluid in nephrotic and hemodialysis patients.

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The CAPD Study Meeting of Shikoku by the Association of Dialysis Doctors of Kochi Prefecture at Kochi City was held on June 30, 1987 and the discussion was on the “Present Situation of CAPD Therapy in Shikoku District.”
In addition, the result of the questionnaire as to the present situation of CAPD in Shikoku, which was in advance conducted on the dialysis patients in the three institutions in Kochi, was also reported and discussed.

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Twenty six hemodialysis (HD) patients with a high risk of bleeding were treated with nafamostat mesilate (FUT-175) as an anticoagulant. It is necessary to measure celite coagulation time (CCT) during HD to determine the optimal dose of FUT-175. As a tube applied to Actester^®, which was developed for the measurement of ACT (activated coagulation time), contained celite, we thought that ACT might be useful for determining the optimal dose of FUT-175
Because the measurement of CCT is more intricate than that of ACT, we examined the correlation between ACT, CCT and coagulation time by the Lee-White method, when FUT-175 was used during HD. The dose of FUT-175 ranged from 30mg/h to 40mg/h, but one patient needed 80mg/h of FUT 175 to prolong eoagulation time in the extracorporeal circuit. We measured coagulation time by three methods at one hour after the start of HD in both the systemic circulation and extracorporeal circuit. A positive linear correlation was observed between ACT and CCT (y=18.79x+54.09, r=0.90, p<0.001), CCT and the Lee-White method (y=0.17x+1.02, r=0.88, p<0.001), and ACT and the Lee-White method (y=3.77x+60.23, r=0.84, p<0.001).
The optimal dose of FUT-175 to performed HD without risk of bleeding ranged from 20mg/h to 80mg/h; the mean dose was 35mg/h. This dose was enough to prolong coagulation time in the extracorporeal circuit without any change in coagulation time in the systemic circulation
In conclusion, the measurement of ACT by Actester^® was useful to determine the optimal dose of FUT-175 to perform HD without any change in coagulation time in the systemic circulation.

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We studied plasma erythropoietin (EPO) concentration in patients with chronic renal failure who underwent regular hemodialysis. Plasma EPO concentration was measured in 67 hemodialysis patients and 16 normal controls by radioimmunoassay using anti-EPO antibody derived from rabbits immunized with human recombinant EPO.
Plasma EPO concentration in dialysis patients was 19.4±3.0mU/ml (mean±S. E. M., range 5.0-176), significantly higher than the mean value of normal controls; 13.3±0.4mU/ml [range 7.7-20.4] (p<0.05). There was no significant difference in plasma EPO between male and female dialysis patients, and plasma EPO did not correlate with hematocrit, hemoglobin concentration or age. However, the length of hemodialysis showed a positive correlation with plasma EPO (r=0.41). Polycystic kidney disease patients manifested higher plasma EPO concentration than other kidney disease patients (p<0.05).
In conclusion, because plasma EPO concentration in hemodialysis patients was higher than in normal controls and showed differences in various diseases with renal failure, it is important that it be considered in the treatment of patients with anemia due to chronic renal failure.

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Predictive values of serum bone Gla-protein (BGP) and alkaline phosphatase (ALP) for bone histology were evaluated in 39 hemodialysis patients. All patients underwent bone biopsies, and serum levels of BGP and ALP were measured at the time of biopsy.
Osteoblastic activity correlated well with serum BGP, and somewhat less well with serum ALP. Serum BGP showed a highly significant correlation with the tetracycline labeling rate, corrected mineral appositional rate, and bone formation rate. These histomorphometric parameters were significantly correlated, but to a lesser degree, with serum ALP. Osteoclastic bone resorption was also correlated with serum BGP, but only marginally with serum ALP. Furthermore, serum BGP showed a significant negative correlation with the corrected mineralization lag time, bone formation period, the [resorption+reversal] period, and remodeling period. In contrast, weak correlations, of none at all, were found between serum ALP and these histomorphometric parameters.
The data indicate that serum BGP is a good marker for evaluating bone remodeling (bone resorption, formation and mineralization) in hemodialysis patients, and serum ALP mainly reflects bone formation activity by osteoblasts. Serum BGP seems to be a better index of bone turnover than serum ALP in hemodialysis patients.

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A 30-year-old woman was admitted to a hospital because of food poisoning, hypoproteinemia and acute renal failure. She was transferred to our hospital for treatment of acute heart failure complicated by pulmonary edema five days after admission. Her condition was rapidly improved by massive removal of body fluid by ultrafiltration and hemodialysis. She was diagnosed as having acute heart and renal failure.
She had no past history of heart disease, but under went an artificial abortion at the 16th week of pregnancy, two months before admission. Ultrasonic echocardiography on admission revealed a marked decrease in fractional shortening (14.0%) and ejection fraction (29.8%), but these parameters improved greatly to 32.6% and 61.6%, respectively, after 3 weeks.
These findings suggest that cardiac contractility was reduced, possibly due to myocarditis after artficial abortion, immediately followed by renal failure. It is possible that dehydration due to food poisoning and enterocolitis triggered the acute heart and renal failure in a hyponutritional state. We conclude that this case is “variant” peripartum cardiomyopathy complicated by acute renal failure.

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