Carpal tunnel syndrome is a major complication in long-term hemodialysis patients. Fifty-two patients on hemodialysis for periods of over five years were examined physically and by electrodiagnostic studies. The mean duration of hemodialysis was 8.5±2.6 years, and the mean age was 48±12 years. The patients' bilateral hands (total 104 hands) were divided into three groups: Group A with symptoms such as paresthesia and pain, 4 hands (3.8%); Group B with no subjective symptoms but abnormal neurological findings such as Tinel's sign and positive Phalen test, 17 hands (16.3%) and group C with symptoms or abnormal neurological findings, 83 hands (79.8%). Electrodiagnostic studies consisted of evaluations of median and ulnar motor nerve conduction velocity, distal motor latency (DML) and the difference between median nerve DML and ulnar nerve DML (median-ulnar difference). There was no correlation between median-ulnar difference and ulnar motor nerve conduction velocity. On the other hand, DML was significantly prolonged with decreases in ulnar motor nerve conduction velocity. The reslts of this study suggest that median-ulnar difference is more specific than DML in the diagnosis of early-stage carpal tunnel syndrome in hemodialysis patients.

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Significant improvement in the prognosis of longstanding, end-stage renal disease has occurred with the progress in new blood purification methods. However, difficult problems like hemodialysis amyloidosis and inveterate hypotension can develop in long term hemodialysis patients. Renal transplantation is expected to solve these problems and to provide a comfortable quality of life in end stage renal disease.
The present study was conducted to characterize the clinical significance of renal transplantation as a strategy for long-standing, end-stage renal disease. Clinical manifestations and laboratory examinations of 36 recipients who suffered from chronic uremia for over ten years among a total 270 renal transplants performed at Nagoya Second Red Cross Hospital were analyzed. laboratory studies of 16 cases with grafts surviving over ten years revealed normal serum creatinine. Anemia and cardiovascular complications were not found. Every recipient was potentially rehabilitated, although some developed complications of aseptic necrosis of the femoral bone and cataracta. Twenty cases with functioning graft who underwent over ten years of hemodialysis and renal transplantation were also in good physical condition and had normal laboratory tests results. None of them developed hemodialysis amyloidosis or inveterate hypotension.
To characterize the recipients who received immunosuppressive agent ciclosporin (CYA), 119 renal transplant recipients using CYA were studied. Graft survival improved dramatically under CYA treatment. The one-year survival rate for cadaveric grafts was 84% and the three year iate was 67%. Furthermore, complications associated with immunosuppressive therapy were decreased. Although CYA nephrotoxicity is a well discribed problem, careful monitoring of CYA blood levels minimized nephrotoxicity.
Furthermore, nine of eleven cases who received a second graft after losing the first had functioning grafts under CYA therapy.
Recent progress in clinical transplantation has brought safe, successful results into the treatment of chronic uremia.
Combined therapy of hemodialysis and renal transplantation should be considered for well-being and high quality of life in patients with long-standing, end-stage renal disease.

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Amyloid osteoarthropathy was found in 5 (6.6%) of 76 hemodialysis patients who complained of polyarthralgia and gait disturbance. Amyloid osteoarthropathy was suspected in 34 patients (44.7%) who complained of arthralgia. Their arthralgia disappeared or was reduced by HDF or HD using a high-performance membrane.
In the amyloid osteoarthropathies, polyarthralgia and cysts of the hand bones and other bones appeared in all cases, and carpal tunnel syndrome was present in 3 cases. The duration of hemodialysis in the amyloid osteoarthropathies was 127±36 months, longer than that in the patients with suspected amyloid osteoarthropathies and other hemodialysis patients.
In the amyloid osteoarthropathies, the serum level of, β₂-MG was 48.7±6.4 mg/l, MG 37.7±9.5mg/l and BUN 97±11mg/l, higher than in the patients with suspected amyloid osteoarthropathies and the other hemodialysis patients. We conclude that one of the causes of high levels of β₂-MG and MG is a high production rate induced by superoxidation. For the treatment of amyloid osteoarthropathy, HDF or HD using a high performance membrane was the most effective. Polyarthralgia disappeared or was reduced in 2 to 8 weeks. Steroid was effective.
We must use high-performance membranes in the early stage of hemodialysis treatment to prevent amyloid osteoarthropathy.

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A 34-year-old was treated for 7 years with hemodialysis.
Gynecomastia occurred in the second year. Refeeding estrogen and gynecomastia were considered to have caused this phenomenon. Surgical mastectomy was performed. Renal osteodystrophy was manifested 4 years later. He developed multiple rib fractures with chest pain, caused by too much phosphate in his high-calorie diet. Hyperphosphatemia, 2°HPT and bone resorption were considered to be the pathogenesis. Alminum hydroxide was most effective for this complication.
Acute pneumonia producing a lung abscess in the left lower lobe followed an upper respiratory tract infection in March of the 7th year. His condition was sometimes serious. He was successfully treated by antibiotics and blood transfusion.
Hormonal disturbance was implicated in the former complications and an immunocompromised state in the latter.

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To investigate the efficacy of calcium carbonate (CaCO₃) for hyperphosphatemia, hypocalcemia, metabolic acidosis and bone metabolism in patients undergoing maintenance hemodialysis, the relationship between doses of CaCO₃ and various hematological parameters, bone minerals was studied. Four patients with hyperphosphatemia and hypocalcemia undergoing maintenance hemodialysis (2 men and 2 women, 46-72 years old, duration of hemodialysis: 48-133 months) took oral CaCO₃ at doses of 1.0, 3.0, or 5.0g/day for 6 months. Calcium, phosphorus, alkaline phosphatase, C-PTH, calcitonin, BUN, creatinine, magnesium, PH and bicarbonate were measured at regular intervals. Bone minerals were also measured by the microdensitometry method. Bicarbonate hemodialysis was done in all patients. The dialysate calcium level was 3.5mEq/l.
Calcium increased in 2 patients but decreased in I. Phosphorus decreased dose-dependently in 3 patients, Calcium phosphorus product and alkaline phosphatase decreased dose-dependently in 3 patients. C-PTH decreased in I patient but increased in 1. Calcitonin increased in 3 patients, but after administration of CaCO₃ 5.0g/day for 6 months, it decreased in all patients. BUN and creatinine increased in 2 patients. Magnesium also increased in 2 patients. PH and bicarbonate remained the same in 2 patients, but decreased in the other 2. Alkalinization was not recognized in any patients. Among the bone minerals MCI increased dose-dependently in I patient, but ΔGSmin, S. GS/D and F·GS decreased in all patients.
No overall amelioration of bone metabolism was recognized. During CaCO₃ administration, blood pressure remained almost stationary in all patients. No clinical or biochemical side effects were recognized in any patients during the administration of CaCO₃. It was concluded that the effect of CaCO₃ as a phosphate binder was dose-dependent, and below 5.0g/day, was sufficiently effective to ameliorate hyperphosphatemia. Higher doses of CaCO₃ were necessary to ameliorate hypocalcemia, metabolic acidosis and bone metabolism in patients undergoing maintenance hemodialysis. Suitable doses of CaCO₃ must be further investigated.

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Various problems, including particularly a new one associated with peritoneal function, have been pointed out in continuous ambulatory peritoneal dialysis (CAPD), since long-term CAPD has become feasible. We experienced a patient with deteriorated ultrafiltration ability probably accompanied by dysfunction of the peritoneal membrane at 4 years after the start of CAPD. To evaluate peritoneal function in this patient, we examined glucose reabsorption from dialysis fluid into plasma, D/P ratio for urea, peritoneal membrane area and PDC concentration in returned dialysis fluid, and comparisons of these parameters were made with another patient with satisfactory ultrafiltration. In addition, peritoneal function in this patient was reevaluated after transient cessation of peritoneal dialysis for three months without removing the catheter (referred to as “peritoneal rest”).
This study yielded the following results:
1) In the patient with deteriorated ultrafiltration, the amount of glucose reabsorbed from the dialysis fluid and D/P ratio for urea were higher than those in the patient with satisfactory ultrafiltration, indicating that the former patient tended to have a hyperpermeable peritoneal membrane. It was also found that these parameters were improved after peritoneal rest of 3 months in the patient with deteriorated ultrafiltration 4 years after starting CAPD.
2) PDC concentration in the returned dialysis fluid was higher after peritoneal rest of 3 months than before peritoneal rest.
3) The amount of water removed during CAPD increased after peritoneal rest of 3 months.
4) There was no problem in maintaining the CAPD catheter.
These results suggest that it is necessary to consider peritoneal rest before giving up CAPD by removing the catheter in managing patients with deteriorated ultrafiltration ability.

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We report a case of a 41-year-old female patient with pheochromocytoma associated with chronic renal failure.
The metabolism of catecholamines (CA) in a patient with chronic renal failure and the effects of hemodialysis are discussed.
As the molecular weights of dopamine (DA), norepinephrine (NE) and epinephrine (EPI) are 153, 169.18 and 183.2, respectively, it is reasonable to assume that CA are eliminated by the hemodialysis.

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The clinical effects of chronic administration of fat emulsion to patients with advanced chronic renal failure were studied. The fat emulsion used in this study was 20% Intralipid (Otsuka Pharmaceutical Co., Tokushima, Japan).
The disapperance rate of administered fat emulsion was determined after the intravenous infusion of 250ml of Intralipid. The serum lipid concentration returned to the basal level after 24 hours, The clinical effects of the long-term administration of fat emulsion in these patients were evaluated at two and four weeks. The daily dose in the long-term study was 250ml of Intralipid. A slight increase in the concentration of serum trigliceride was observed at both points: From 151.1±38.4mg/dl to 191.3±58.9mg/dl at two weeks and to 201.9±52.2mg/dl at four weeks. The serum albumin concentration was significantly elevated from 3.65±0.27g/dl to 4.14±0.44g/dl at two weeks (p<0.01) and to 4.38±0.31g/dl at four weeks (p<0.01). Hematocrit was decreased significantly from 24.0±2.96% to 20.3±2.47% at four weeks in the control group (p<0.05). In contrast, the change in hematocrit in the Intralipid group was insignificant. No adverse effects were observed throughout the study.
From these data, the infusion of fat emulsion to patients with advanced chronic renal failure seems to be safe and useful to improve their nutritional condition.

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Hemodynamics during postural change were evaluated to clarify the mechanism of orthostatic hypotension in hemodialysis (HD) patients. We studied 10 patients (five male, five female), aged 56-79, including 3 with diabetic nephropathy. The duration of HD was less than 4 months in 5 patients and more than one year in 5. Four patients were hypotensive, including 2 with symptomatic orthostatic hypotension after HD, 5 were normotensive and one was hypertensive. Cardiac output and blood pressure were measured at the following angles 0, 10, 20, 30, 45, 60 and 90 degrees, with the patient remaining at each angle for 5 min.
1) Comparing 0 and 90 degrees, systolic blood pressure (SBP) decreased more than 20mmHg in 5 patients, including 3 with diabetes mellitus, and SBP decreased more than 40mmHg in 2 of 5 patients who were asymptomatic. Total peripheral resistance (TPR) increased markedly and SBP did not change in 2 patients who showed orthostatic hypotension after HD.
2) Five patients, whose SBP decreased more than 20mmHg, were divided into 2 groups according to the change in SBP at increasing angles. SBP decreased markedly at 10 degrees but did not change at bigger angles in 2 of 5 patients, On the other hand, SBP was constant from 0 to 30 degrees, but decreased in a linear pattern at bigger angles. Comparing 0 and 90 degrees, TPR decreased in the former, but increased slightly in the latter. Cardiac index (CI) did not change in the former, but decreased markedly in the latter.
3) The patients with HD for more than one year showed lower SBP, lower TPR and higher CI in the supine position than those with HD for less than 4 months. The former showed smaller decreases in SBP and CI in the standing position than the latter.
These results revealed frequent asymptomatic orthostatic hypotension in HD patients without relation to the blood pressure in the supine position. It is suggested that hypovolemia, in addition to autonomic imbalance, contributes to orthostatic hypotension in HD patients.

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To investigate the relationship between protein metabolism and anemia, we analyzed long-term clinical laboratory data obtained from 31 patients maintained with chronic hemodialysis. Autoregressive (AR) coefficients for each patient were computed with the use of the patient's serial data for the levels of total plasma protein (TP), plasma albumin, plasma gamma globulin, and blood hemoglobin (Hb) concentration for 4 to 7 years. The AR coefficents thus obtained were used to make a differential equation, or its equivalent, specific to the patient and thereby to simulate impulse-response (IR) curves. The IR curves clearly demonstrated that an increase in the levels of TP or albumin, but not gamma globulin, caused to strengthen anemia in most patients. This finding suggested the existence of a feedback loop in the body between albumin production in the liver and hemoglobin production possibly mediated by changes in the hepatic production of erythropoietin.

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We evaluate hyperechoic lesions of the aortic valves using the short axis view of echocardiography in 157 patients undergoing maintenance hemodialysis, including with diabetic nephropathy. Their ages ranged from 20 to 76 years, with a mean of 49.8 years. They had been receiving dialysis for between 5 months, and 13 years and 7 months (mean, 6 years and 5 months). Patients with ischemic heart disease as confirmed by coronary angiography and patients diagnosed with echocardiography as having no heart disease were also studied as controal subjects. Hyperechoic lesions were observed in 69 dialysis patients (43.9%), a frequecy similar to the control subjects. The lesions in dialysis patients were mild except for two moderate and one severe lesions. Severe aortic regurgitation was not observed in any patient. The frequency of hyperechoic lesions increased with age in the control subjects, but was similar throughout all age groups in the dialysis patients, probably bocause many hyperechoic lesions were observed in dialysis patients younger than 50 years old. The frequency of hyperechoic lesions was not correlated with the period of dialysis, administration of alfacalcidol, dialysate buffer (acetate/bicarbonate), history of hypertension and smoking, or average predialysis serum concentrations of calcium, inorganic phosphorus, parathyroid hormone and total cholesterol during 2 1/2 years before echocardiography. However, this study could not elucidate whether the hyperechoic lesions originated from sclerotic or calcified changes in the aortic valves.

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In the isolated preparation of vas deferens of guinea pig, we examined the in vitro effects of aliphatic amines, uremic toxins of low molecular weight, on nerve-mediated smooth muscle contractions. The aliphatic amines used were monomethylamine (MMA), dimethylamine (DMA), trimethylamine (TMA) and ethanolamine (ETA).
1) One to two min after the application of MMA or DMA, smooth muscle contraction was inhibited in a dose-related manner in a range of 1-20mg/dl, and four min later it was appreciably augmented.
2) Application of TMA induced considerable augmentation only, whereas application of ETA induced inhibition only, at concentrations within a range of 1-20mg/dl.
3) The early inhibitory effect of aliphatic amines was found to be statistically significant at concentrations of more than 10mg/dl, and the later stimulating effect at concentrations of more than 4mg/dl.
4) The effect of TMA was significantly enhanced in low Ca⁺⁺ and high Mg⁺⁺ solutions.
Since the serum concentrations of aliphatic amines in uremic patients are reported to be no more than 2mg/dl, the results of the present study do not necessarily indicate the existence of acute effects due to aliphatic amines in uremic patients. Nevertheless, it remains to be determined whether prolonged application of aliphatic amines at clinical concentrations would induce the effects observed in the present study.

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