Adverse effects of heparin including lipolytic action, platelet activation, inhibition of aldosterone production, allergic reaction and osteolytic action have been reported. Recently, we experienced three patients with chronic renal failure on hemodialysis who manifested blood coagulation in the hemodialyzer and thrombocytopenia during heparinizing dialysis. We diagnosed them as having heparin-induced thrombocytopenia and treated them with lowmolecular-weight (LMW) heparin on dialysis. We also investigated platelet function in two of them. When LMW heparin was used, hyperactivation of β-TG and PF4 associated with thrombocytopenia were not observed during hemodialysis, in contrast with the use of normal unfractionated (UF) heparin. Furthermore, we found by in vitro study that enhanced platelet aggregation was induced by the addition of UF heparin to a mixture of normal plateletrich plasma, while by the addition of LMW heparin-induced platelet aggregation was not found.
Therefore, we conculuded that LMW heparin was useful for the treatment of hemodialyzed patients with heparin induced immune thrombocytopenia.

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Autosomal dominant polycystic kidney disease (ADPKD) often complicates diverticulitis in the colon in hemodialysis patients.
Barium enema study was performed in eleven hemodialysis patients (three males and eight females, 55.0±3.7% years old, duration of hemodialysis 6.5±4.9 years) (mean±S. D.) and five patients with chronic renal failure with conservative therapy (three males and two females, 51.6±8.6 years old, duration of hemodialysis 3.2±2.0 years) (mean±S. D.) due to ADPKD.
Barium enema was performed in the morning in the hemodialysis patients, most of whom were anuric, with correction afterwards for the influence of hemodialysis on the examination procedure. No accidents occurred in the barium enema study of hemodialysis patients. Of 16 patients examined, 9 (56%) had colonic diverticulosis. The existence of colonic diverticulosis in ADPKD had no relationship to the sex or age of the patient, or to the duration of hemodialysis.
Several patients had colonic diverticules in more than one part of the colon.
The frequency of patients with diverticule in each part of the colon was as follows 8 (87%) in the ascending colon, 2 (22%) in the transverse colon, O in the descending colon and 2 (22%) in the sigmoid colon. Dolichocolon was found in 5 (31%) of 16 patients examined. The existence of diverticle in the colon did not correlate with dolichocolon.
ADPKD should be recognized as a multiple malformation syndrome, having cerebrovascular abnormality, colonic diverticulosis, cardiovascular abnormality, etc. As ADPKD, which is thought to be linked to the short arm of chromosome 16, is not preventable, it is important to avoid severe complications in hemodialysis patient due to ADPKD. Thus, a good understanding of the extent and depth of the disease is required.

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We performed Dylon, Aluminon and Berlin blue staining of bone specimens obtained by ilium bone biopsy from 15 patients before the introduction of hemodialysis.
The patients had no subjective symptoms relating to the bones or joints. Amyloid was present in all 15 patients, aluminium in 8 and iron in 8.
The result revealed that amyloid deposition had already begun in the early stage. The involvement of other factors with aluminium deposition was strongly suspected because aluminium hydroxide gels were not taken.
Furthermore, the staining of amyloid, aluminium and iron was divided into three grades and their relation with serum β₂-microglobulin, aluminium and ferritin levels was examined, but there was no significant relation with individual staining, statistically.
The presence of false negative cases was forlseen and localization of aluminium and iron in the inside of bone was presumed from the fact that there were Aluminon-positive cases, although their serum aluminium level was below the limit of determination, cases in which the serum ferritin level was normal and the test for Berlin blue staining was positive, and those in which the serum ferritin level was abnormally high, but the test for Berlin blue staining was negative. Thus, it is possible that, when the duration of hemodialysis is prolonged, amyloid-related, aluminium-related and iron-related bone disease will appear in all patients, because depositions of amyloid, aluminium and iron were already present in the bone even though no clinical symptoms had been observed before the introduction of hemodialysis.

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A 33-year-old patient had been treated by maintenance hemodialysis for five years when she presented with a 14-week pregnancy. Successful delivery of a healthy but small infant (1584g) was achieved by Caesarean section and supra vaginal hysterectomy (Porro's operation) at 33-weeks of pregnancy. The infant had an Apgar score of 5 at one miunte and 7 at five minutes, and has shown normal development for the four years and seven months since delivery.
Fifteen cases of pregnancy and delivery in patients on regular dialysis had been reported in Japan prior to 1986. We report an additional case.

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A questionnaire study was performed among 23, 209 dialysis patients in 589 institutions in 1982, to clarify the risk and charcteristics of malignancies.
Dialysis patients with malignancies were older than the average dialysis patient population. However, they were younger than those with malignancies in the general population.
The incidence of malignancy in dialysis patients was 476 cases/10⁵ persons·year, 1.3 times higher than the expected incidence in the general population. Mortality was 1.9 times higher in dialysis patients than the expected mortality in the general population. The risk of malignancy was higher in males.
Incidence and mortality were the highest among university hospitals, followed by public hospitals and private facilities. Incidence and mortality were, respectively, 6 and 7 times higher in university hospitals than private facilities.
The frequencies of kidney, bladder, colon, rectum and liver malignancies were higher, and those of esophagus, stomach and pancreas lower in dialysis patients than the expected frequencies in the general population.
The average disease course was 9 months in the patients who died of malignancies.

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The effect of changes in extracellular volume and plasma osmolality on ADH and α-hANP (ANP) release was studied in 10 patients on maintenance hemodialysis. On the day of the study, the patients were treated by a one-hour ECUM followed by a 4-hour conventional hemodialysis session. The following results were obtained.
1) Initial plasma ADH and ANP levels of these patients with maintenance hemodialysis were clearly more elevated when compared with levels obtained in normally hydrated healthy volunteers.
2) The plasma ADH level remained unchanged during ECUM, but fell during hemodialysis. There were no statistically significant correlations between the change in plasma ADH level and those plasma osmolarity and extracellular fluid volume.
3) Plasma ANP level fell significantly after ECUM. There was a statistically significant correlation between the change in plasma ANP level end that in mean blood pressure.

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We studied the effects of the correction of anemia with recombinant human erythropoietin (r-HuEPO) treatment on cardiovascular hemodynamics in maintenance hemodialysis patients.
Six patients, whose average age was 51.7 years and average duration of hemodialysis 60.7 months, received intravenously either 1, 500 or 3, 000 units of r-HuEPO three times a week, at the end of each hemodialysis. Before and after 8 to 18 weeks (mean; 11.5) of r-HuEPO treatment, the patients cardiovascular function was examined by Swan-Ganz thermodilution catheter.
Hematocrit increased significantly from 17.4±0.8% to 26.9±1.4% (p<0.001) and whole blood viscosity increased significantly from 2.50±0.07cp to 2.95±0.05cp (p<0.001). Body weight, cardiothoracic index on chest X-ray films, heart rate and mean arterial blood pressure showed no significant changes. On the other hand, the cardiac index decreased significantly from 6.09±0.21l/min/m² to 5.60±0.24l/min/m² (p<0.05). Peripheral vascular resistence increased from 998±108 dyne·sec·cm^-5 to 1206±75 dyne·sec·cm^-5 (p<0.1). The stroke volume index decrease from 82.5±5.0ml/m² to 69.5±2.8ml/m² (p<0.1).
In conclusion, the correction of renal anemia with r-HuEPO treatment improved cardiac output without increasing mean arterial blood pressure. This treatment was considered to have a benefical effect on cardiovascular hemodynamics in maintenance hemodialysis patients with severe anemia.

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In an attempt to clarify causes of gastric mucosal lesions in hemodialysis (HD) patients, gastric mucosal blood flows (GMBFs) were endoscopically measured in healthy persons (n=25) and HD patients (n=28) using a laser doppler blood flowmeter. In the gastric antrum, GMDFs of the HD patients (lesser curvature: 20.4±6.8ml/min/100g; greater curvature: 19.0±8.3ml/min/100g) were almost equivalent to those of healthy persons (lesser curvature: 23.0±7.1ml/min/100g; greater curvature: 19.2±5.9ml/min/100g). On the other hand, in the gastric body, the GMBFs (upperbody greater curvature: 19.8±6.4ml/min/100g; lower body lesser curvature: 18.7±5.9ml/min/100g) showed lower values than those of healthy persons (upper body greature curvature: 26.2±8.5ml/min/100g; lower body lesser curvature: 24.4±8.1ml/min/100g), suggesting that HD patients tend to have stress-induced lesions in the gastric body. However, it is known that gastric lesions in HD patients usually occur in the region of the gastric antrum, and accordingly, GMBF changes are not thought to account for gastric lesions. Further studies are, therfore, required to clarify the causes of gastric mucosal lesions in HD patients.

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Kuntz et al reported recently a new syndrome characterized by the development of destructive spondylarthropathy (DSA) in patients on long-term hemodialysis (HD). The diagnosis of DSA was based on the following radiologic signs: 1) severe narrowing of the intervertebral disc, 2) erosions and geodes of the adjacent vertebral plates and 3) absence of significant osteophytosis. The identification of hydroxyapatite crystals in 1 disc specimen led to the suggestion that hydroxyapatite crystal deposition may account for this syndrome. Sebert et al performed a pathological study in 4 long-term HD patients with DSA. It showed that DSA was associated

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In administering drugs to patients on maintenance hemodialysis, it is necessary to carefully adjust the size of individual doses and the intervals between them. However, even if the overall metabolism of drugs, including absorption, binding ratio to serum protein, excretion and dialyzability, are considered, a variety of unanticipated adverse drug reactions may occur.
We report five cases of severe drug-related disorders experienced in patients undergoing long-term maintenance hemodialysis therapy. Two patients developed disorders of the central nervous system caused by drug accumulation: isoniazid (INH) to the slow acetylator and overdoses of acyclovir. In one patient, severe intrahepatic cholestasis was observed. The positive drug lymphokine stimulation test indicated that this was attributable to a drug administered for flu-like symptoms (Pyrex^®). Exacerbation of anemia with captopril was seen in one patient. The other patient suffered pericarditis, myocarditis and pleuritis and died during the treatment of secondary hemosiderosis with deferoxamine (DFO). Autopsy revealed cardiac mucormycosis and pulmonary embolism (mucor as emboli). It has been speculated that iron-bound DFO may be associated with the growth of mucor. When the drugs were discontinued, all patients except one (mucormycosis) followed a favorable clinical course.
Since these drugs are not uncommonly prescribed for dialysis patients, their adminitsration should be carefully monitored in daily practice. It should always be kept in mind that drug toxicity may occur even when administration is performed according to the general guidelines for drug regimens.

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A rare case of a mamushi poisoning in a chronic hemodialysis patient is reported. A 36-year-old male on chronic hemodialysis was bitten on the left leg by a mamushi (Agkistrodom Halys Blomhoffi). Soon after the bite, the affected left leg swelled and was painful from the foot to the thigh. Systemic symptoms included nausea, dyspnea, a sense of chest compression and diplopia. Serological data revealed elevated CPK, myoglobin and potassium, suggesting rhabdomyolysis. The patient was treated as an extremely serious case of mamushi poisoning. Hyperpotassemia and hypovolemia were the most problematic in his clinical care. The patient improved on the third hospital day, and was cured by the 14th day. It was noteworthy that mamushi poisoning in a chronic hemodialysis patient tended to be more severe than in normal healthy individuals, It should be borne in mind that the hyperpotassemia derived from rhabdomyolysis and hypovolemia due to serous exudation in the swollen extremity are most important in the care of mamushi poisoning in a chronic hemodialysis patient.

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The purpose of the present study was to investigate the hemoglobin (Hb) concentration and maximal exercise capacity required to improve the fitness level of chronic hemodialysis (HD) patients. Twenty-seven female HD patients and ten female controls were used as subjects. Their number of steps were measured by a pedometer. Their Hb concentrations and maximal oxygen uptake (VO₂max) were measured before HD treatment. The results were as follows:
The number of steps in HD patients was 26.2% lower than that of the controls. Untrained subjects' steps were lower than those those of trained subjects. Housewives step were lower than those of workers. The number of steps in patients was inversely proportinal to age, whereas there was not correlation between number of steps and age in the controls. The number of steps became constant in HD patients at an Hb concentration of 8.2g/dl and did not increase even with increased Hb concentration. This level was equal to that of the control subjects. The number of steps was significantlycorelated with VO₂max rates in HD patients. In conclusion, the present observations suggest that the Hb concentration required to improve fitness level was 8.2g/dl when number of steps were used an index. The VO₂max rate required to improve it was possible to estimate in HD patients.

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