In order to clarify the effect of hemodialysis (HD) on the fibrinolytic system, fibrinolytic activity was evaluated in 27 patients undergoing regular hemodialysis treatment, using new parameters including alpha 2-plasmin inhibitor (α₂PI), alpha 2-plasmin inhibitor-plasmin complex (α₂PIC) and FDP-D dimer (D-dimer). α₂PIC is regarded as a good parameter of in vivo plasmin production and D-dimer as a good one of fibrinolysis secondary to coagulation. Plasma antigen levels of α₂PI and α₂PIC were determined by the one step sandwitch EIA method. Plasma α₂PI activity was measured by the specific tripeptide substrate method. Predialysis levels of α₂PIC were significantly higher in reqular hemodialysis patients than in normal controls (p<0.01). During HD, α₂PIC exhibited a continuous significant increase and reached up to about 180% of the starting values until the end of HD (p<0.001). α₂PI activity was significantly decreased at the end of the HD (p<0.05). α₂PI antigen was significantly reduced at 60 minutes after starting HD (p<0.05). D-dimer was significantly increased at 60 minutes and at the end of HD (both, p<0.05) and the peak values of D-dimer were obtained at 60 minutes. There were no significant changes in fibrinogen, plasminogen activity and AT III activity during HD. The findings of α₂PI and α₂PIC suggest that fibrinolytic activity is slightly increased in regular hemodialysis patients and is still more enhanced during HD. The increment in D-dimer during HD suggests that enhanced fibrinolysis during HD in partly related to fibrinolysis secondary to coagulation.

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Atherosclerotic change is a very important complication in hemodialysis patients. We therefore measured aortic pulse wave velocity (PWV) in hemodialysis patlents and studied the relationship between PWV and the risk factors for a therosclerosis.
PWV was measured just after hemodialysis in each patient by MCG-400 (Fukuda). The subjects consisted of 14 patient with diabetes mellitus (DM group, mean age 58.6y) and 57 cases without diabetes mellitus (non-DM group, mean age 56.0y). The average duration of hemodialysis was 1.0 year in the DM group and 2.3 years in the non-DM group.
The results were as follows: 1) PWV was significantly higher in the DM group (10.4m/sec) than the non-DM group (8.4m/sec). 2) In both groups, there was a positive correlation between age and PWV, and a negative correlation between the duration of hemodialysis and PWV. 3) There was a positive correlation between systolic blood pressure and PWV in the DM group, but none in the non-DM group. 4) In the DM group, there were negative correlations between PWV and LDL, VLDL, apo B, apo E and LCAT, but there were no correlations in the non-DM group.
In conclusion, the PWV of the DM group seemed to be high, especially in patients with advanced, hypertension, poor-nourishment or in the early stage of hemodialysis.

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In the past five years (1983-1987), 107 malignancies were diagnosed in 106 patients on hemodialysis therapy in Hokkaido. The dialysis population increased in number from 1, 865 to 3, 228 during this period.
In this series, there was a broad spectrum of malignancies with a preponderance of gastric cancer (28 cases), cancer of colon and rectum (17 cases), renal cancer (12 cases), hepatic cancer (10 cases) and pulmonary cancer (10 cases).
Cancers of the digestive system accounted for 62% of all malignancies, while sarcoma was found in only 2 cases. In 24 of 107 cases (22.4%), the diagnosis was established within one year from the onset of dialysis therapy. Of the patients with malignancies, 77.8% were over 51 years of age.
During the five years investigated, 64 of 106 cases (60.4%) died and 54 cases (84.3%) died within one year after the diagnosis; thus, the over-all prognosis was extremely poor.
The most predominant malignancy, gastric cancer, accounted for 26.2% of all reported malignancies, almost the same as in the general population. In contrast, renal cancer was observed more frequently in dialysis patients than in the general population. This fact was estimated to be closely related to acquired cystic disease of the kidneys, which is predominant and specific in long-term chronic dialysis patients.

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We studied the influence of protein intake on T-lymphocyte subsets in 48 patients on maintenance hemodialysis. The patients were 26 males and 22 females, ranging in age from 19 to 80 years, with an average of 55.6 years. All patients were being maintained on long-term hemodialysis (mean 37.7 months). They were divided into three groups according to protein intake: Group A, less than 1.1g/kg/day; Group B, 1.1-1.5g/kg/day; and Group C, more than 1.5g/kg/day. There were no significant differences between the three groups with respect to age and period of maintenance hemodialysis. We measured protein intake and T-lymphocyte subsets.
No significant differences were found between the three groups with respect to the percentage of OKT3 and OKT8 positive cells. The Percentage of OKT4 positive cells was lower in Group A. The OKT4/OKT8 ratio was low in Groups A and C. The results suggest that protein deficiency impaired cellular immunity in maintenance hemodialysis patients. Furthermore, excess intake can have a detrimental effect on cellular immunity. Therefore, adequate protein intake should be maintained in the interests of optimizing cellular immunity.

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Two cases with chronic renal failure (CRF) who received cardiac surgery are described. A 48-year-old female, who was maintained on intermittent peritoneal dialysis for acute exacerbation of CRF with diabetic nephropathy underwent successful direct closure of ASD. A 54-year-old female who had CRF with serum creatinine of 4.6mg/dl caused by nephrosclerosis underwent mitral valve replacement and tricuspid annuloplasty for combined valvular heart disease. No hemodialysis or hemofiltration was performed during cardiopulmonary bypass, and the postoperative course was uneventful in both cases.
Cardiac surgery in patients with CRF should be perfomed without delay because the control of complications related to renal failure such as hypervolemia, hyperkalemia and bleeding tendency is much easier in CRF patients than in those with end-stage renal failure on maintenance hemodialysis.

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We evaluated, from the nursing standpoint, the effectiveness and limitations of calcium carbonate as a phosphate binder in 25 patients receiving hemodialysis.
Oral aluminum hydroxide gel was discontinued, and the same dose of calcium carbonate was substitued at the start. The dosage of calcium carbonate and 1α (OH) D₃ were adjusted accordingly, aming to keep serum Ca below 11.0mg/dl and serum phosphorus below 7.0mg/dl. Five patients dropped out of the study, 2 because of gastrointestinal distress, and 3 because of hyperphosphatemia. After 12 months on this regimen, the serum aluminum concentration in 20 patients whose hyperphosphatemia was controlled with calcium carbonate alone had fallen significantly from 92.4±43.1 to 34.3±10.5μg/l (p<0.01). Tansient hypercalcemia. (>10.8mg/dl) was observed in ten of the 20 patients. At the final obsevation, mean serum Ca, phosphorus and AI-p were unchanged, while serum PTH increased significantly (p<0.05).
About half of the patients complained that it was more difficult to take cailcium carbonate than aluminum hydroxide gel, because the former was in powder form.
After dietary phosphate reistriction, the serum phosphate level in 3 patients showing hyperphosphatemia decreased and aluminum hydroxide gel was stopped.
We considered education about low phophate diet necessary in patients with hyperphosphatemia undergoing calcium carbonate therapy.

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We report six cases of sudden deafness in hemodialysis patients: 2 males and 4 females with a mean age of 55.8 years and a mean duration of hemodialysis of 54 months. Although they had no paticular family history, four cases had suffered from otological diseases. The onset of sudden deafness occurred immediately after hemodialysis in one patient, but hearing loss did not occur during or after hemodialysis in the others. All cases were diagnosed as definite cases of sudden deafness based upon the criteria of the “Sudden Deafness Research Committee” of the Ministry of Health and Welfare, Japan. Three cases improved in hearing ability, but the others did not. We have experienced 6 cases of sudden deafness among about 450 hemodialysis patients during 6 years. Viral infection, vascular impairment of the cochlea and external lymphorrhea are the most common etiologicai factors in sudden deafness. Hemodialysis patients would have a predispotision to viral infections because of the decline in immunity, and renal anemia, hypertension and arteriolosclerosis would impair the blood flow of the inner ear. Therefore, it should be noted that hemodialysis patients are more susceptible to sudden deafness than healthy persons.

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According to the Manual for Medical Examination of AIDS Patients by the Ministry of Health and Welfare, hemodialysis of HIV antibody-positive patients is classified as an operative procedure (level III). In this manual, the preventon of HIV infections in hemodialysis is also described. However in reality, no institution in Japan has ever performed hemodialysis on an AIDS patient. Therefore, procedures for the hemodialysis of such patients have yet to be established here.
The patient, a 46-year old female, had been receiving hemodialysis since May 1980. She had been receiving washed cell transfusion for anemia and also received a large blood transfusion for an operation for cancer of the cervix in March 1985. Laboratory examination in May 1987 showed that HIV antibody and antigen were positive, and she was transfered to our hospital. In September 1987, it was also confirmed in our hospital that HIV antibody and antigen were positive. Diarrhea and oral candidiasis appeared on October 5, and were healed by treatment with an anti-fungial drug. After she entered our hospital far high fever on October 21, disturbance of consciousness and clonic cramp appeared, and she died of an unknown cause on November 2, 1987.
We performed hemodialysis on this HIV infected patient by means of a dedicated hemodialysis machine located in a separate part of the hemodialysis room partitioned off by curtains. We used the gown technique and goggles during blood access and at the end of hemodialysis. Since the most dengerous accident for HIV infection is a stab wound from a contaminated needle, we put the needles into a polyethylene bottle immediately after the punctureing her shunt. During hemodialysis, injections were performed by a infusion or an air trap line of the circuit without a needle. Disposable products were discarded after machanical sterilization, and the machine, bed and floor of the room were sterilized with sodium hypochlorite and alcohol.
This patient apparently suffered from AIDS and died with in a short period of time. We have had valuable experience in establishing a guidelines for the hemodialysis of AIDS patients in our hospital.

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Low phosphate diets for the treatment of hyperphosphatemia in patients on chronic hemodialysis have been drawing attention. We investigated the effect of low phosphate milk. In 32 patients on hemodialysis, 100ml of low phosphate milk (LPK^®) dissolved in 20g warm water were given once a day for one month to observe changes in Ca and P values before and after administration. For comparison the same quantity, 100ml of milk available on the market (control milk) was administered in 5 of them and changes in Ca and P values were compared 2 hours after administration.
The mean values of serum phosphate before and 4 weeks after administration of low phosphate milk in 32 patients were 6.7±1.1mg/dl and 5.5±1.2mg/dl, the latter being a significantly low value (p<0.005). Similarly, the [Ca×P] levels were 65.6±14.3 (before) and 53.2±12.2 (after), with the latter significantly lower (p<0.005). However, in 8 patients who had less than 6mg/dl of serum phosphate at the start of administration, no significant difference was noted. In the 5 patients who were given control milk, the mean value of 4.6+0.6mg/dl (before) increased to 5.1±0.6mg/dl (2 hours later), while the mean values with low phosphate milk were 4.9±0.3mg/dl (before) and 4.7±0.5mg/dl (2 hours later), exhibiting no appreciable difference.
These findings suggest that low phosphate milk is ureful in lowering the serum phosphate level and normalizing tce [Ca×P] level against hyperphosphatemia in patients on chronic hemodialysis.

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Cutaneous microvascular blood flow (CMBF) was measured by laser Doppler flowmetry, to examine the effect of blood access (BA) on cutaneous microvascular circulation. We studied 10 normal subjects and 10 hemodialysis (HD) patients (male 3, female 7) who had arteriovenous shunt on the right or left forearm. Two patients showed luxurious perfusion. We made flow measurements in the center of the back of both hands in the resting supine position before and after HD, and 1 and 2 hours after HD started.
1) CMBF on the BA side (6.36-30.7ml/min/100cc) was markedly higher than on the non-BA side (1.62-4.21ml/min/100cc) in 4 patients, including 2 with swollen hands. This increased flow gradually decreased during HD, but 3 of the 4 patients showed transient elevation 1 hour after HD started. Of these 4 patients, the CMBF after HD on the BA side in the 2 patents with swollen hands were 3.3 and 7.3 times greater than on the non-BA side, but in the other 2 patients, they were 1.4 and 1.7 times.
2) The CMBF before HD in the remaining 6 patients ranged from 3.09-5.30ml/min/100cc on the non-BA side and 1.57-5.05ml/min/100cc on the non-BA side, and it did not change during HD.
3) There was no significant difference in CMBF on the non-BA side between the patients and normal subjects (1.10-4.34ml/min/100cc), and no correlation between CMBF and peripheral venous hematocrit.
It is suggested that the increase in CMBF on the BA side depends on the massive inflow of arterial blood through the BA, and the measurement of CMBF is useful for the treatment and prevention of Iuxurious perfusion induced by BA.

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