The upper gastrointestinal roentgenogram series was conducted on 250 patients treated by chronic maintenance hemodialysis, and the patients were divided into four groups according to roentgenographic findings: normal group, chronic gatritis group, gastroduodenal ulcer group, and others. The age distribution, sex ratio, duration of hemodialysis, biochemical data (BUN, Creatinine, Na, K, Ca, IP, C-PTH), blood pressure variations during hemodialysis, coefficient of variation (CV) for the R-R interval on the electrocardiogram (ECG) and subjective symptoms of autonomic imbalance (orthostatic dizziness, vertigo, palpitation, constipation, diarrhea, gastric retention, abnormal sweating, edema and paruria) were compared among these groups.
The average age and proportion of males were higher in the ulcer group than in the normal group, but there was no significant difference in duration of hemodialysis between the normal and the disease groups. Pre-dialysis biochemical data did not significantly differ between the normal and the disease groups, but the post-dialysis improvement in blood level of IP was less marked in the ulcer than in the normal group. Systolic blood pressure variations during hemodialysis were significantly greater in the ulcer than in the normal group, but CV was slightly lower in the ulcer group, while subjective symptoms of autonomic imbalance were slightly more intense in the ulcer group.
Our findings give support to the assumption that diminished gastric mucosal protective factors due to a decrease in mucosal blood flow under the conditions of hypotension may be involved in the development of a peptic ulcer concerning the influence of autonomic imbalance and inorganic phosphorus, further studies are warranted.

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The usefulness of the anatomical snuff box arterio-venous (A-V) fistula was examined in hemodialysis patients with chronic renal failure (44 procedures). Successful results were obtained in all but 9 ox the 44 procedures. There were relatively more diabetic and elderly patients in the unsuccessful group of cases than in the successful group. At present the successful A-V fistulas are functioning excellently. It was concluded that in hemodialysis patients this type of A-V fistula should be one of the procedures of choice.

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This study was performed to investigate the psychological condition of patients with chronic renal failure (CRF). The subjects were 81 patients with CRF with ages ranging from 18 to 65 years. Forty-one were male and 40 were female. They were subdivided into three groups. Group A included patients with end-stage chronic renal failure (n=16, M:F 13:3), group B consisted of patients on hemodialysis (HD) for less than 1 year (n=25, M:F 14:11), and group C patients had been on HD for over 1 year (n=40, M:F 14:26). The psychological condition was determined by a quality of life scale (e.g., thirst, hypotension and lumbago), which has been popularized to assess everyday life, an analog scale, and self-rating questionaire for depression (SRQ-D) (Toho University method), which is a useful marker of depression. The following results were obtained.
In the quality of life score, there was no characteristic difference in the incidence of each symptom between the three groups. In all three group, over 90% of the cases suffered from anxiety. In group A, 70% continued to work and 50% had changed their jobs. In group B and C, 50% and 30% continued to work respectively. A few other patients from each group found re-employment and job satisfaction. The analog scale mean values were 53.4, 61.2, and 59.5 in group A, B, and C, respectively. Depression was recognized in 62%, 20% and 45% of the cases in group A, B, and C, respectively.
The present study led us to conclude that it is necessary to reduce the anxiety about death and to provide adequate counselling from doctors and medical coworker when patients are put on HD.

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We experienced a rare case of hemophilia A which required hemodialysis for acute renal failure due to bilateral urinary tract obstruction. This 23-year-old male was diagnosed with hemophilia A at the age of 2 years. He visited a family doctor with macroscopic hematuria and lower back pain in 1988. Three days later he was referred to our hospital because of anuria. Abdominal computed tomography revealed bilateral renal enlargement and pelvic and urinary tract thromboses. Laboratory findings indicated renal failure and he was diagnosed as having acute renal failure caused by bilateral obstruction of the urinary tract. Four hemodialyses improved the patients general condition and laboratory findings. In hemophilia patients, the severe bleeding tendency makes it difficult to perform hemodialysis, but we managed successfully in this case using replacement of factor-VIII, FOY or local heparinization, and an EVAL membrane dialyzer.

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The frequency of HLA-DRw13 in 22 Japanese patients with malignancy and end-stage renal disease on maintenance hemodialysis or just before its commencement was statistically higher than that in 472 normal controls (50% vs 6.1%, Pc<0.0006). No association was found with the type of malignancy or end-stage renal disease. It appears that the immune responses to malignancy were reduced in the patients with chronic renal failure and HLA-DRw13.

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For the purpose of evaluating the availability of plasma ultrafiltrate sampled during dialysis as analytical specimens, several chemical subutances in ultrafiltrate were measured and compared with their levels in plasma. In all substances including each guanidino compounds, A estimated value calcurated from ultrafiltrate levels and clearance levels was found to be highly correlated with actual levels in plasma.
This study has demonstrated that plasma ultrafiltrates directly sampled from dialyzers are suitable as analytic specimens instead of blood samples in practical clinical laboratories.

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To consider measures to be taken for emergency operations on hemodialysis patients, 20 patients on whom abdominal surgery was recently performed (12 elective operations and 8 emergency operations) were selected mainly to study changes in the circulation by using a Swan-Ganz catheter. In the case of elective operation, the cardiac index (CI) was reduced to the normal lower limit before the operation, but soon improved to show no change in the pulmonary arterial diastolic pressure (PADP) thereafter, maintaining a stable condition of cardiac function.
In the case of emergency operation, on the other hand, insufficient removal of water and the critical cause of the disease had increased PADP before the operation, but it recovered to normal after the operation, which was performed after the removal of the cause by an operation. After the operation, both CI and PADP were increased, showing a tendency toward an increase in cardial load. As to the water balance during the operation, the fluid balance during elective operation was 3ml/kg/hr, while it was increased to 4.6ml/kg/hr during emergency operation. Dialysis was performed 14.6±3.2hr. after emergency operation, significantly earlier than the 29.3±12.6hr. after elective operation.
From the above findings the, in the case of emergency operation, the following points should be taken into account: 1. Perform emergency dialysis as much as possible before the operation. 2. Provide a circulation monitor and set the fluid volume according to the monitor. 3. Remove the cause of the disease as early as possible by an operation. 4. Perform dialysis as early as possible after the operation. Emergency operations on dialysis patients should be performed with the above points kept in mind.

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A 61-year-old female dialysis patient with stable angina was observed while on coronary vasodilator therapy. Because her condition became unstable with an increase in the frequency of anginal attacks, cardiac catheterization was performed. Ninety-percent stenosis of the left main trunk was demonstrated, precluding the possibility of percutaneous transluminal coronary angioplasty, and A-C bypass surgery was indicated. Marked discomfort, however, developed in the chest during dialysis 7 days before the scheduled operation. This attack of angina was not relieved by the administration of a coronary vasodilator, and the patient lapsed into shock. Her blood pressure was restored by vasopressor medication, but the long duration of the attack suggested transition from unstable angina to threatened infarction. An emergency A-C bypass procedure was performed, and the angina disappeared. Emergency operation of dialysis patients is considered to involve high risk, but it can be performed with sufficient maintenance dialysis and appropriate postoperative management.

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The present study was undertaken to find out if the seroconversion rate for hemodialysis (HD) patients was enhanced by intradermal (ID) inoculation of recombinant hepatitis B (HB) vaccine.
Thirtyfive HBs-Ag, -Ab, HBc-Ab negative HD patients were divided into three groups: 14 patients (Group I) received 5μg of HBs Ag ID every two weeks, 13 patients (Group II) were given 2.5μg of HBs vaccine ID every two weeks, 5 times, then every week. The remaining 8 patients (Group III) were injected intramuscularly (IM), with 10μg of HBs Ag every four weeks 5 times then with 5μg ID, every two weeks until complete seroconversion.
Antibody response to IM injection was poor and only 37.5% of the patients had developed anti-HBs antibodies at a titer of 10mIU/ml or more by 16 weeks after the start of immunization. However, this poor response was improved by ID injection. The time of seroconversion was significantly earlier and the rate of response was higher in Group I.
The poor response in Group II was markedly improved by doubling the inoculation rate. Overall 100% seroconversion was finally obtained by multiple ID injections. However, the anti-HBs antibody titers were lower in all patients and declined in some patients after discontinuation of immunization. We feel that the ID route remains a useful and cheaper method of obtaining prophylaxis against HB in high risk HD patients but it would seem to be prudent to monitor these patients serially to assess the persistence of anti-HBs antibody in the serum.

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We investigated 50 parathyroidectomized patients on maintenance hemodialysis and found amyloid deposition in the parathyroid glands of 47 of them. Nine of the 47 patients underwent surgery for carpal tunnel syndrome, and amyloid deposition was found in the transverse carpal ligaments.
Histological examination showed the presence of amyloid deposits in the capsular septal walls between nodules, and in the small artery walls of the parathyroid glands.
Recent studies indicate that β₂-microglobulin (β₂-MG) is the major constituent protein in this new form of amyloidosis. The amyloid deposits in our studies were resistant to potassium permanganate (nonAA protein) and reacted with anti-human β₂-MG antibody in immunohistochemical studies (peroxidase-antiperoxidase method, immunofluorescence method). These findings suggest that dialysis amyloidosis may be systemic, and that amyloid substance may be deposited in systemic organs.

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To estimate the flow volume in an arteriovenous dialysis shunt (A-V shunt) and its effect on cardiac function, we investigated the A-V shunts of 12 chronic dialysis patients (8 men, 4 women; mean age 51.8 years) by using an ultrasonic pulse doppler flowmeter. Also, cardiac output was estimated with an M mode ultrasonic cardioscope (Teicholtz method) and by the RI method (first pass method). The flow rate for each vessel was measured by calculating the product of the mean time velocity integral (which is half of the maximum time velocity integral) and the sectional area. The shunt flow rate was measured by calculating the difference between the right brachial artery flow rate and the left brachial artery flow rate.
The mean shunt flow rate was 521ml/min (maximum; 1, 096ml/min, minimum; 150ml/min), and the ratio of the shunt flow rate to cardiac output was 11.3% (maximum; 25.1%, minimum; 2.6%) by the Teicholtz method and 11.7% (maximum; 27.1%, minimum; 2.5%) by the first pass method.
All but one patient had an adequate A-V shunt flow rate (more than 200ml/min), and underwent dialysis with no problem. Therefore dialysis A-V shunt requires at least 200ml/min.
The color doppler method enabled us to estimate the type of flow. Surface vessels near the A-V shunt showed a mozaic pattern, which meant turbulent flow formation.
The measurement of shunt flow by the pulse doppler method is simple and easy. However there exist some problems: 1. The probe should be positioned as parallel to the vessels as possible. 2. The vessel should not be pressed by the probe. 3. This method should be used only for the vessels which have laminal flow, not turbulent flow. Therefore the precise shunt flow rate is not obtained by measuring the flow rate of a surface vessel near the A-V shunt whose flow is turbulent, but by the difference between the right brachial artery flow rate and the left brachial artery flow rate.

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A patient maintained on chronic hemodialysis for 7 years and 8 months and in a stable state had a large amount of bilateral hemorrhagic pleural effusion. From his clinical symptoms, findings on effusion and its progress, we considered the effusion to be from uremic pleuritis.
Case history: A 50-year-old male patient had chronic hemodialysis started in April 1979 because of worsening of chronic glomerulonephritis and he progressed favorably thereafter. However, in his periodical chest X-ray examination in December 1986, bilateral effusion was pointed out but he had no subjective symptoms.
Then he developed fever, cough, chest pain and dyspnea which all gradually increased. CRP was 3+, and leucocytosis was noted, but a tuberculin skin test was negative. The first diagnostic thoracocentesis yielded exudative hemorrhagic fluid with a hematocrit reading of 2% and showing high levels of pleural protein at 5.6g/dl, LDH at 847U and glucose at 88mg/dl. Cultures for bacteria including Mycobacterium tuberculosis were negative and cytological examination was evaluated as Class I. Unlike the transudative effusion on overhydration, the pleural effusion did not respond to fluid restriction and aggressive dehydration hemodialysis. The subsequent clinical dilatory course and bilateral thoracocentesis were repeated 15 times, requiring 5 months for improvement. Slight restrictive pulmonary dysfunction remained.

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