In order to make nutrition advice more acceptable in end-stage renal disease patients on chronic hemodialysis, a questionnaire study concerning the actual daily diet of their families, their awereness of salt intake as well as their use of seasoning was conducted. 163 outpatients on hemodialysis served as subjects of this study. It was evident, first, that most patients enjoyed the same daily diet as their families in reducing total intake. Second, when dialysis duration became longer, they demonstrated more skill in reducing their salt intake from their daily diet. On the other hard, fewer patients on longterm hemodialysis were careful about their selection of seasoning.
Estimated salt intake calculated from inter-dialysis body weight gain in the 225 anuric patients was approximately 9.8g/day, farexceeding the prescribed level. No positive relationship was found between the amount of salt inkate and dialysis duration. Lastly, the newly-developed salt-restricting soy sauce with low potassium and low phosphorus was evaluated among 33 outpatients and their families for two weeks. The majority of the participants rated it satisfactory.
In conclusion, our present study revealed that the dietary instruction of hemodialysis patients has to involve not only the patients but also their families. Seasoning which could be accepted by both patients and their families was used effectively and comfortably in such situations.

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We investigated the mental states of 20 hemodialysis patients transferred to our unit for surgical treatment of complications. Our investigation was conducted by questionnaire. The surgical procedures consisted of gastrectomy, nephrectomy, hysterectomy, total hip joint replacement and renal transplantation. Concerns related to surgery were the same as in non-hemodialysis patients. The kind of concerns related to hemodialysis involved hemodialysis methods and schedules, hyperkalemia, body weight gain due to infusions, etc. Kidney transplant patients had little anxiety about postsurgical dialysis therapy, however, they had a great deal of anxiety about whether the operation would succeed or not.
These results indicate that patients transferred to our unit for surgery should be encouraged by providing sufficient information about surgery and continued hemodialysis therapy after surgery.

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In order to clarify intracellular potassium metabolism in acute and chronic renal failure, the authors measured erythrocyte potassium (RK) and sodium (RNa) levels in groups of healthy controls, chronic renal failure patients, regular hemodialysis patients, acute renal failure patients, and recovered acute renal failure patients, and then discussed the results obtained in relation to the disease underlying the renal failure. As a result, RK was found to be significantly lower in the group of patients with chronic renal failure who did not undergo dialysis than in the group of healthy controls. This may be explained by the involvement of a substance removed by hemodialysis rather than in terms of abnormal acid-base equilibrium.
There was no significant difference between the RNa of the group of chronic renal failure patients without dialysis and the groups of healthy controls or hemodialysis patients. In the acute ranal failure group, RK decreased from onset to the most severe stage, but improved to the level of the healthy control group after recovery, indicating that the RK decrease is related to a substance which is rapidly accumulated in the body. The RNa of this group was high in the acute phase and remained higher than that of the healthy control group after recovery, suggesting involvement of a disease different from chronic renal failure.

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Several reports, including our own, have established that isosorbide dinitrate (ISDN) tape is very useful in the treatment of angina attacks during hemodialysis. The plasma concentration of ISDN and its residual concentration in the ISDN tapes were measured after the application of ISDN tape (ISDN 40mg) in 8 patients undergoingchronic maintenance hemodialysis (53-77 years, 7 males, 1 female, mean maintenance hemodialysis period 36 months), demonstrated to have coronary heart disease. ISDN tape was applied to the abdominal skin of patients 2 hours (h) before hemodialysis. Plasma was obtained 0, 1h, 4h and 48h later, then the tape was removed. It was found that 1. Plasma ISDN concentration was maintained at 1.2ng/ml during hemodialysis but varied from individual to individual; 2. Plasma ISDN concentration was significantly lower in the venous blood line than in the arterial blood line after 4h; 3. A significant negative correlation was found between the plasma concentration of ISDN and its residual concentration in the ISDN tape (p<0.01). These data indicate that the absorption of ISDN through the skin is variable, but measuring the residual concentration in the tape makes it possible to estimate the plasma concentration of ISDN, and this method may might become available for clinical use instead of the very troublesome direct assay of the plasma concentration of ISDN.

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We retrospectively investigated the prognosis of patients on continuous ambulatory peritoneal dialysis (CAPD) instituted between 1983 and 1988 at our hospital in March, 1990. Of the 31 patients (22 males and 9 females), whose mean age was 47 years old, 10 patients (32%) were switched to hemodialysis (HD) mainly because of peritonitis, 2 patients (6%) underwent renal transplantation, 4 patients (13%) died and 15 patients (48%) remained on CAPD. Patient selection and education in the prevention of peritonitis are important in maintaining patients on CAPD, because peritonitis was the main reason for switching them to HD.

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The quality of life (QOL) of hemodialysis (HD) patients was evaluated on the basis of a questionnaire assessing the significance of alexithymia in QOL taking into account the interrelationship between QOL and alexithymia, which is closely related to the self-control of HD patients. The subjects of this study were 194 HD patients classified on the basis of underlying disease, method of treatment, age, and sex.
There was a significant negative correlation between QOL evaluation and alexithymia with respect to 3 out of the 11 items, i.e., emotions, social relations and satisfaction with life, however, there was no significant correlation with respect to any of the remaining 8 items. Such a QOL dissociation in terms of psychosociological and medical aspects suggests the need for comprehensive assessment of QOL in HD patients. On the other hand, even though the psychological aspects of QOL seem favorable, patients often exhibit poor self-control due to alexithymia. Thus, the psychological aspects of QOL are apparently good in many cases. It is important then to evaluate the QOL of HD patients from several aspects, including the study of alexithymia, a psychological index reflecting degree of self-control.

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We performed the following clinical study to determine the effect of the protein binding ratio (PB) of cephem antibiotics (CA) on their dialysance. After obtaining informed consent, 1g of one of the seven types of CA (CAZ, CZX, CXM, CTX, CFX, CMZ, CPM, in order of their PBs, CAZ having the lowest at 17% and CPM the highest at 96%) was administered intravenously to each of six chronic maintenance hemodialysis patients at the beginning of each hemodialysis (HD). At the end of 1hr of HD, CA concentrations (CAC) at an inlet and an outlet of the dialysers were measured. The dialysers used were of the hollow fiber type, made of PMMA, with a surface area of 1.0m². Blood flow and water removal rate were adjusted to 150ml/min and zero, respectively, at the time of measurement. Neither the CAC of the A-lines nor the removal rates (RR) of the CA were very different from one another among most types of CA so long as PB was no more than 70%, but at higher PBs, the former increased and the latter decreased. At lower concentrations of Alb, the main binding protein of CAs, there was a tendency for CAC to decrease and the RRs of CA to increase. It is generally accepted that drugs with higher PB are less dialysable, however, we did not obtain the same results in the case of CA. We believe that because of their loose protein binding, molecules of most kinds of CA move so quickly from the bound to the free state that the effect of PB on their dialysance is relatively weak. In the case of high-PB CA, however, protein binding is strong enough to reduce dialysance. The dialysance of high-PB CA on the other hand, is not very low at lower Alb concentrations because the CA binding sites are readily saturated and the number of free molecules becomes large.

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AMTEC QC-70 is a new sterilizing agent containing anthium dioxide, detergent and EDTA-2Na. We examined the effectiveness of this new agent with respect to its sterilizing and cleaning properties.
1. Its sterilizing effect was examined in test tubes using three different strains of bacteria. AMTEC exhibited sterilizing activity approximately equivalent to that of Purelox (sodium hypochlorite) in relatively high concentrations. 2. Piping, heavily smeared with organic substances was washed with several gradient-diluted solutions of AMTEC, and residual protein, fat and calcium were stained by the Ponceau 3R, Sudan black and OCPC methods, respectively. The cleaning power of AMTEC increased dose-dependently, and the above substances were completely removed using the 70-fold diluted solution. 3. A 700-fold diluted solution of AMTEC was used daily to sterilize the dialysate supply systems in our hospital. The results showed that the number of bacteria in the samples of dialysate and RO-treated water were markedly lower after rinsing with AMTEC than after the previous method.
The deposition of organic substances not only provides a breeding ground for bacterial growth but inhibits the power of conventional chloride-derived agents such as Purelox. AMTEC has both sterillzing and cleaning ability, therefore it is the most effective agent for washing dialysate supply systems. Furthermore, the metal corrosion produced by rinsing with acidic agents has been the main cause of damage to hemodialysis machines, however, we no longer need to use acetic acid, because AMTEC is capable of removing calcium deposits from the piping. In addition, it is alkaline, and hemodialysis machines and dialysate supply systems are hardly damaged at all by rinsing with AMTEC.

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A 43-year-old female with a 4-year history of hemodialysis was hospitalized because of fever, painful skin eruptions and myalgia. There was no response to antibiotic treatment. Since a biopsy specimen of the skin lesion revealed dense dermal infiltration with neutrophils, a diagnosis of Sweet's syndrome was made. Steroid therapy resulted in rapid symptom resolution. To our knowledge this is the first case report of Sweet's syndrome in a patient on maintenance hemodialysis.

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Recently, the number of patients being treated by continuous ambulatory peritoneal dialysis (CAPD) has been gradually increasing. The most common and important complication of CAPD is infection, e.g., acute bacterial peritonitis and subcutaneous pericatheter infection. We experienced a case complicated by massive pleural effusion in the initial phase of institution. Although pleural effusion is a rare complication of the CAPD, this condition is extremely important because continuation of treatment is relatively ineffective. According to the literature, 43 patients with the same complication have been reported. Almost half of the cases complicated by pleural effusion were switched to chronic hemodialysis due to the difficulty of treatment. On the other hand, 8 cases were able to continue on CAPD after conservative treatment alone, such as decreasing dialysate volume or temporary discontinuation of CAPD.
These facts indicate that the etiology of the massive pleural effusion during CAPD was not single. CAPD is a very useful system for managing end-stage renal failure, and pleural effusion cannot be detected before the institution of CAPD. Therefore, cases complicated by pleural effusion must be examined to determine whether CAPD can be continued or not.

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A 48-year-old-woman placed on maintenance hemodialysis presented with swelling of her left arm and left jugular vein soon after the creation of an arteriovenous fistula on her left arm. Intracorporeal pressure during hemodialysis was found to be high. Venography showed severe stenosis of the left innominate vein accompanied by rich collateral circulation. Ligation of the patient's fistula promptly relieved the swelling of both her left arm and her left jugular vein. The exact cause of stenosis could not be determined on the basis of venographic or computerized tomographic findings.

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Recently, bone cystic radiolucency has become familiar as a complication in long-term dialysis patients. It is mainly caused by dialysis amyloidosis and rarely by infectious involvement of the appendicular skeleton. Here we present a hemodialysis patient with tuberculous arthritis of the elbow. A 56-year-old male with end-stage renal failure due to chronic glomerulone phritis had been treated by hemodialysis for 12 years. He first developed left elbow joint pain and swelling in June, 1988. The aspirated elbow joint fluid proved sterile on culture. Radiographs showed extensive cystic lesions of the trochlear eminence of the humerus thought to be due to dialysis amyloidosis. The lesion was partially filled by fibrous tissue, curetted thoroughly and an iliac crest graft was added. Histological examination revealed granulomas consisting of central necrosis, epithelioid cells and multinucleated giant cells of the Langhans type. No amyloid deposits were detected. Cultures of the joint fluid revealed Mycobacterium tuberculosis. Antitubercular drugs were given postoperatively. Convalescence was uneventful. Tuberculosis of the elbow in hemodialysis patient has not been reported previously. It is important to differentiate dialysis amyloidosis from tuberculous arthritis, because both show similar radiographic findings.

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Acetazolamide inhibits carbonic anhydrase and is clinically used in the treatment of glaucoma and epilepsy in children instead of diuretic agents. We experienced two patients with chronic renal failure who became somnolent a few days after oral administration of acetazolamide. Patient 1 was 62-year-old man with a two-year history of hemodialysis. He became somnolent 3 days after daily administration of acetazolamide (0.5g/day) for the treatment of an episode of glaucoma. Patient 2 was a 54-year-old man with chronic renal failure due to diabetic nephropathy. Somnolence followed 3 days of administration of acetazolamide (0.75g/day). In both cases normal consciousness returned soon after the discontinuation of acetazolamide. The electroencephalograms of both were compatible with metabolic encephalopathy. Based on these findings, we believe that accumulation of acetazolamide because of failure to be excretion by chronic renal failure patients in turn causing cerebral metabolic acidosis was responsible for the consciousness disorder.

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