There are several reports, including those by Ito et al. of our own hospital, on the results of cataract operations (intracapsular cataract extraction: ICCE) in patients undergoing hemodialysis. However, hemodialysis patients are already socially handicapped, and there would be many problems if they are burdened with the additional handicaps of aphakic patients. The results of planned extracapsular cataract extraction (p-ECCE) and intraocular lens implantation (IOL) in such patients are reported.
P-ECCE and IOL were performed in eight cases, i.e., in 13 eyes of hemodialysis patients with indications for cataract operations, who requested implantation IOL, in the period from September, 1983 to April, 1986.
No abnormal findings were noted in the postoperative course which has ranged from a minimum of 2 months to a maximum of 2 years and 9 months, paticularly compared with the natural course of the aphakic eye thus far. Preoperative visual acuity was 0.1 the light sense meaning and postoperative acuity was 0.1 to 1.2, all the cases having improved. Compared with the report of Ito et al. in 1984 on ICCE, p-EECE and IOL are considered to be a safe operations not at all less advantageous than the former ICCE, and especially advantageous with respect to the daily life activities of patients with dialysis who have handicaps.

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Pregnancy and delivery have been considered contraindicated in patients with maintenance HD because of both high maternal and fetal risks, though pregnancies were rare in such patients. However, recent remarkable progress in HD techniques as well as good control of patients with maintenance HD has made pregnancy and delivery successful. At least 12 such cases have been reported in Japan upto now. This report describes a case of successful delivery.
The patient, 32 years old, with a 7 year history of maintenence HD became pregnant and came under our care 14 weeks later. Throughout her pregnancy BUN and S-Cr were set to be controlled below 60mg/dl and 6mg/dl, respectively. Dry weight was determined by estimating the volume of amniotic fluid and fetal weight. Systolic BP was controlled so as to maintain it at a level of no less than 100mmHg during each dialysis. HD was performed using low dose heparinization.
At 32-weeks and 2-days of pregnancy she delivered a girl by Caesarean section. Her Apgar score was 9 point and her general condition was good, except for a body weight (BW) of 1454 gr. The baby was cared for at NICU and was able to be discharged with a BW of 3310 gr 60 days after birth. Four months after delivery BW had increased to 5450 gr and no abnormalities have been observed. The mother returned to regular HD immediately after delivery and has been well controlled since then.
The factors contributing to success in this patient are believed to be as follows, 1. excellent self-control, 2. cooperation of the family, 3. cooperation of the nephrologist, gynecologist and pediatrician in caring for both mother and baby. 4. Good HD control (BUN<60mg/dl, S-Cr<6mg/dl and Ht>30%) during pregnancy. Another factor contributing to success was the fact that the patient was able to continue pregnancy for more than 30 weeks and that the baby was able to grow over 1000 gr.
We feel that patients undergoing maintenance HD who want to have a baby should been informed that pregnancy and delivery in patients on maintenance HD are not always safe and require great effort on the part of the patient herself as well as her family and the medical staff.

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Selenium (Se) concentration in the serum of 25 healthy persons (Normal Group), 13 non-dialyzed uremic patients (CRF Group), 53 patients undergoing chronic hemodialysis (HD Group) and 25 patients undergoing continuous ambulatory peritoneal dialysis (CAPD Group), was determined.
Mean Se concentrations in the CRF Group, HD Group, and CAPD Group were significantly lower than in the Normal Group, and in the CRF Group were significantly lower than in the HD Group.
In the CRF Group there was a significant positive correlation between serum Se concentration and red blood cell count, and between serum Se concentration and hematocrit values as well.
These results suggest that the decreased serum Se concentration in the CRF Group might be caused by anemia.
In the HD Group, there was a significant negative correlation between serum Se concentration and HD duration.
In the CAPD Group there was a significant negative correlation between serum Se concentration and CAPD duration.
These results showed that the decreased serum Se levels in the HD and the CAPD Groups caused by prolonged dialysis treatment.
The rate of decrease during prolonged dialysis treatment is higher in the CAPD Group than in the HD group.
On the other hand, in 12 HD patients, the plasma Se concentration after HD was significantly higher than the serum Se concentration before HD, but when plasma Se concentrations after HD were corrected for hematocrit values, there was no significant difference.
These results suggest that patients with low selenium levels, especially long term CAPD patients might be at risk because of selenium deficiency, i. e., risks of increased incidence of cancer, muscle pain, decreasing immune function and cardiovascular disease etc.

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Patients with chronic renal failure (CRF) incur high risks in pregnancy, and it is difficult for them to have babies. We report 2 cases of successful pregnancy and delivery managed with hemodialysis treatment.
The first case was a 29-year-old woman who came to our hospital at 15 weeks' gestation. Her serum Cr was 4.4mg/dl, and we were afraid that her renal failure might progress during gestation. But she strongly insisted on having a baby, and her course was monitored as an inpatient. At 21 weeks' gestation, her BUN rose to 77.9mg/dl and her Cr was 5.2mg/dl. Hemodialysis was carried out 3 to 4 times weekly with the goal of keeping her predialysis BUN below 50mg/dl. She also required 32 units of blood to keep her hematocrit above 25%. Danger of premature labour occured at 23 weeks, but pregnancy was maintained until 32 weeks. She gave transvaginal birth to a male infant weighing 1, 790g with an Apgar score of 8. During the postpartum period, the mother and baby had no problems and hemodialysis was discontinued.
The second case was a 30-year-old woman who started dialysis at 27 years old who had CRF due to chronic glomerulonephritis. She was transferred to our hospital at 19 weeks of gestation. She was dialysed 4 times weekly to maintain her BUN below 50mg/dl. She was also transfused with 34 units of blood to keep her hematocrit above 25%. At 33 weeks she transvaginally delivered a boy weighing 1, 690g with an Apgar score of 9.
Although few data exist on pregnancy in patients with renal failure, successful pregnancy may be maintained by careful and intensive management.

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The authors investigated aluminum (Al) accumulation in the red blood cells (RBC-Al) of chronic renal failure patients treated by different modalities and the effect of desferrioxamine (DFO) infusion on RBC-Al and anemia. No s-Al or RBC-Al was detected in healthy volunteers.
Non-dialyzed patients had high levels of RBC-Al, and their levels fell between those of CAPD and HD patients. In HD patients, there was a positive correlation between s-Al and dose of Al hydroxide, but no correlation between the dose and RBC-Al levels. HD patients who were not given Al hydroxide also had high levels of RBC-Al.
S-Al levels increased 2 days after administration of DFO, and then decreased to the baseline levels by day 7. No significant changes in RBC-Al levels occurred for one month after DFO infusion, suggesting that changes in RBC-Al are independent of changes in s-Al. In the in vitro study, RBC-Al was removed by ultrafiltration.
Our data suggest that Al accumulates in RBC in renal failure patients independent of the changes in s-Al.

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To deal with intractable hypercholesterolemia complicated by ischemic heart disease, LDL apheresis (LDL-AP) has been performed continually and problems concerning LDL-AP-treatment were examined.
Eight familial hypercholercholesterolemia patients and two diabetic nephropathy patients who underwent hemodialysis received LDL-AP twice a month amounting to a total of 150 times.
The following four points were listed as important problems.
1) Acquiring sufficient skill and technique in preparing and operating equipment 2) Devising methods to secure aceess for the bloodstream via a peripheral vein 3) Observing hemodynamics in detail during treatment 4) Introductory patient education to continue treatment without disturbing social rehabilitation
Nursing guidelines for LDL-treatment were made up with concern for these matters.

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The food consumed by 30 dialysis patients was recorded for two or three consecutive off-dialysis days. The dietary data were calculated using Japanese tables of food composition.
The mean dietary intake of crude fiber was 2.4g/day in dialysis patients, 2.2g/day in the males and 2.5g/day in the females. These values were nearly equivalent to the mean crude fiber content of 2.6g/day in the dialysis diet and 2.8g/day in the renal failure diet, in contrast to 4.9g/day in the normal diet at Keio University Hospital. The crude fiber intake of dialysis patients corresponded to around 40% of the daily intake of an average Japanese. There was no remarkable change in crude fiber intake according to age, weight or height of the dialysis patients. Crude fiber intake, potassium intake and fruit and vegetable intake were well correlated with each other in dialysis patients.
Our study demonstrated that the dietary intake of crude fiber was limited in dialysis patients. The reason is likely the limited intake of fruits and vegetables due to the severe restriction on potassium intake in dialysis patients.

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The purpose of this study was to evaluate the usefulness of continuous equilibration peritoneal dialysis (CEPD), a method similar to continuous ambulatory peritoneal dialysis (CAPD), in non-ambulatory, hospitalized diabetics with end-stage renal disease (ESRD).
CEPD was applied to 12 uremic diabetic patients who had complications and/or concomitant disorders that prevented them from tolerating extracorporeal hemodialysis using anticoagulants. Of the 12 patients, four had acute myocardial infarction, six had congestive heart failure, three had cerebrovascuiar accident, one had diabetic gangrene which required amputation, three had intravitreous hemorrhage and two were critically hypotensive during hemodialysis. Six patients were dialyzed by the peritoneal route initialy, while the remaining six were switched from hemodialysis to CEPD.
After a chronic Tenckhoff catheter was surgically implanted, CEPD was initiated using 0.5-2.0 liters of dialysate in a plastic bag. To obtain adequate removal of nitrogenous waste and its by-products, 7.1 liters of dialysate were required per day on an average. Renal failure was safely controlled in these hemodynamically unstable or hemorrhagic patients in 38.6 patient months. Complications observed during CEPD were peritonitis, subcutaneous tunnel infection, and exit site infection, each of which occured at a rate of one episode per 38.6 patient months.
Although six patients died during CEPD, none of these deaths was related to renal failure or nephrological disorders. The causes of death were as follows: pneumonia in four cases, brain stem herniation in one, and lactic acidosis in one. The average duration of CEPD in these patients was 125 days. Of the remaining six patients, five were switched to hemodialysis after being cleared from the critical stage and the other is continuing peritoneal dialysis at home (CAPD).
We would like to recomend CEPD as the ideal treatment for ESRD in hospitalized diabetics with systemic complications.

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Follow-up studies on 54 patients who underwent continuous ambulatory peritoneal dialysis (CAPD) in Tokai University Hospital were performed from April 1, 1984 to March 31, 1988, to clarify the significance of patient selection and the incidence of CAPD-related peritonitis. We divided the patients into two groups: a positive-selection group (PS) and a negative-selection group (NS). Patients who were strongly motivated initiate CAPD were defined as PS. Conversely, those who showed little motivation were defined as NS. Of the 54 patients, 42 were in the positive-selection (PS). group and 12 in the negative-selection (NS) group. The drop-out rate was low (7.1%) in the PS group after the exclusion of patients who had switched to transplantation or were transferred to other clinics, whereas the drop-out rate was high (66.7%) in the NS group, including patients who died of underlying diseases (62.5%) or switched to hemodialysis (HD) (37.5%). The rate of CAPD-related peritonitis was low (0.58/patient year) in the PS group and high (2.13/patient year) in the NS group. There were significant differences in drop-out rate and incidence of CAPD-related paritonitis between the two groups. In the PS group, the causative agents of peritonitis were predominantly of the gram-positive coccal group (57.2%). In contrast, the causative agents varied from gram-positive cocci or rods (26%) and gram-negative cocci or rods (26%) to fungi (22%) in the NS group. Six patients the NS group dropped out following candida peritonitis, whereas there were no such patients in the PS group. In conclusion, the successful outcome of CAPD may depend on the motivation of patients without underlying diseases in addition to the quality of treatment and prevention of CAPD-related peritonitis.

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We conducted a questionnaire examination on perspiration and itching in patients on maintenance hemodialysis. The subjects were 500 patients receiving hemodialysis at 8 different institutions (286 males and 214 females, ranging in age from 10 to 76 years, the average being 52 years). Of the subjects, 63.1% were affected with itching, and in 60.3% of them, itching exceeded moderate intensity, to the extent that it interfered with their everyday lives. Among the subjects, 42.5% complained of itching all over the body, 30.5% reported an outbreak of itching within 1 year of hemodialysis, and 48.4% noticed paucity of perspiration as well. Of the whole population, 38% noticed paucity of perspiration within 1 year of hemodialysis; 56.1% also noted dryness of the skin, and 36.7% ascribed the itching to the paucity of perspiration. A majority of patients expected that parspiration would contribute to the excretion of wastes in lieu of their malfunctioning kidneys, as well as to the regulation of body temperature. Of the whole population, 19.6% perspired equally before and after the initiation of hemodialysis. It was suggested that the deficiency in perspiration frequently observed in patients on hemodialysis would be improved if the skin were stimulated by physical exercise or hot baths.

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Using a continuous hematocrit measuring system and a Swan-Ganz catheter, we investigated changes in circulating blood volume and hemodynamic parameters before, during and after dialysis-induced hypotension. When dialysis-induced hypotension occurred, cardiac output dropped sharply, and concomitant sudden decreases were observed in mean pulmonary arterial pressure and mean right atrial pressure. These were attributed to decreased venous return. Since there was no recognizable change in blood volume when blood pressure dropped sharply, the decrease in venous return was considered to be caused by relocation of the circulating blood, possibly associated with a sudden increase in venous capacity.

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