The effect of volume removal during hemodialysis on blood pressure, plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were studied in 19 maintenance dialysis patients with normal blood pressure. The patients were divided into three groups on the basis of their underlying disease, i.e., chronic gromerulonephritis (CGN, N=6), diabetes mellitus (DM, N=7), and polycystic kidney (PCK, N=6). Basal PRA (0.74±0.15ng/ml/hr) and PAC (29.8±5.0pg/ml) were very low, and systolic blood pressure decreased significantly during dialysis in the DM group when compared with other groups. Failure to stimulate either PRA or PAC was observed during hypotension. Volume removal by dialysis significantly increased the PRA levels of the CGN group (8.00±2.41 vs 13.78±3.83ng/ml/hr, p<0.05) and PCK group (2.84±0.86 vs 5.19±1.86ng/ml/hr, p<0.05). On the other hand, PAC levels did not respond to dialysis in all groups. These results suggest that impaired renin release following hypotension as a result of dialysis may represent autonomic dysfunction in DM patients and that the renin-angiotensin system is maintained in dialysis patients in the CGN and PCK groups. Moreover, it appears that the low basal level of PRA in the DM group may reflect functional or organic damage to renal tissues sufficient to release renin.

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Osteocalcin (bone gla-protein) is a low-molecular-weight vitamin K-dependent protein which is a sensitive and specific marker of bone turnover. To determine whether serum osteocalcin is a useful indicator for parathyroidectomy in patients with RHP, we measured serum osteocalcin levels (normal<6.5ng/ml), and compared them with patient symptoms, X-ray findings and biochemical data. Thirty seven RHP patients who were followed up for more than six months after parathyroidectomy were studied. All patients underwent total parathyroidectomy and parathyroid autotransplantation. Controls consisted of 46 non-operated patients undergoing chronic maintenance hemodialysis for more than three years. Serum osteocalcin levels were markedly increased in 37 patients with parathyroidectomy, ranging from 4.2ng/ml to 645ng/ml, with a mean value of 278.8±159.8 (M±SD)ng/ml versus 65.0±85.2ng/ml in the 46 controls (non-operated patients) (p<0.001). Patients with high osteocalcin levels had severe bone pain and X-ray findings of severe osteotis fibrosa. Serum osteocalcin was found to be significantly (p<0.001) correlated with both serum ALP and m-PTH. The total mean weight of the parathyroid tumors resected was 2, 152±1, 368mg (M±SD), ranging from 200mg to 5, 600mg, and was significantly (r=0.656, p<0.001) correlated with the osteocalcin level. These results suggest that osteocalcin measurement is a sensitive method for detecting increased bone turnover and is possibly useful as an indication for parathyroidectomy in patients with RHP.

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Serum erythropoietin (EPO) titers in patients undergoing chronic regular hemodialysis (HD), with iron deficiency anemia (IDA) and in normal adult controls were determined using radioimmunoassay (RIA). The results are summarized as follows: 1. The EPO titers of 100 patients with HD (two cases were excluded due to polycystic kidney) were 11.0±5.3mU/ml, of 41 patients with IDA were 37.4±118.5mU/ml, and of 73 normal adult controls were 14.9±4.6mU/ml. 2. Correlations obtained between EPO titers and hemoglobin (Hb) volumes are as follows: IDA: r=-0.80, y=7, 726e^-0.63x, HD: r=-0.16, y=14.4e^-0.044x. The differences between the two disease groups based on these results suggest that the lower the Hb levels, the wider the dissociation tendency. 3. Accordingly, serum EPO levels were found to be markedly lower in HD than in IDA.

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During the fifteen-year period from February, 1974, to December, 1988, 96 patients were admitted to the Nagasaki Municipal Medical Center for dialysis therapy of acute renal failure (ARF). The mean age of the patients was 61.1 years, there were 66 males and 30 females, and these accounted for 16.0% of 599 cases including chronic renal failure.
In this study, we evaluated only ARF (78 cases). The patients were grouped into fourteen etiologic categories, i.e., dehydration (22), shock (15), antibiotics (11), hepatorenal syndrome (7), drug intoxication (6), hypercalcemia (3), postoperative (3), contrast medium (2), DIC (2), Weil's disease (2), rhabdomyolysis (2), renal infarction (1), myeloma (1) and RPGN (1).
The renal recovery rate was 72.7% (16/22) in dehydration, 33.3% (5/15) in shock, 72.7% (8/11) in the case of antibiotics and 55.1% (43/78) overall. Survival rates were 63.6%, 26.7%, 36.4% and 43.6%, respectively. Most of these patients had multiple organ failure of the heart, lung, liver, intestine, central nervous system, coagulation and infection. And the total number of organs involved per patient was inversely correlated with renal recovery and survival rate. Among patients with no organ failure, the renal recovery and survival rates were 78.6%, respectively, but in patients with failure of four to six organs the figures were 33.3% and 11.1%, respectively.
These data suggest that complications and multiple organ failure play an important role in the prognosis in acute renal failure.

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Renal osteodystrophy with secondary hyperparathyroidism is a troublesome complication in hemodialysis patients. It has recently been reported that intermittent oral administration of 1, 25-dihydrocholecalciferol (1, 25-(OH)₂D₃) suppressed serum parathyroid hormone (PTH) levels in nine hemodialysis patients. We examined this pharmacological parathyroidectomy (pulse therapy) in uremic patients in 15 hemodialysis units. Two to 6mg of 1, 25-(OH)₂D₃ was administered orally twice weekly to 26 hemodialysis patients whose serum carboxy-terminal PTH (C-PTH) levels were greater than 7.0ng/ml.
Five of the 26 patients withdrew from treatment because of hypercalcemia (>11.0mg/dl). Serum midregion PTH fragment (HS-PTH) was measured using the PTH kit “Yamasa” before and 4, 8 and 12 weeks after 1, 25-(OH)₂D₃ administration. A marked decrease in HS-PTH level was noted in 21 patients 12 weeks after the pulse therapy, but in 5 patients HS-PTH levels were elevated or unchanged at 4 weeks after therapy compared with the level before treatment (slow responder). The HS-PTH levels of 16 other patients were decresed by 28% at 4 weeks compared with the initial values (fast responder). In one patient, the HS-PTH level was decreased after the administration of 1, 25-(OH)₂D₃ (2mg), This decrease occurred although her plasma Ca was not elevated (8.5mg/dl).
Our results indicated that the suppression of serum parathyroid hormone level by 1, 25-(OH)₂D₃ was not uniform among hemodialysis patients, as indicated by the fast and slow responders. It was also suggested that 1, 25-(OH)₂D₃ directly suppressed parathyroid function.

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A 71-year-old female farmer with acute renal failure induced by mamushi viper venom is reported. She was admitted to our hospital suffering from uremia, three days after being bitten by the snake. She fell into a drowsy state and her leg was found to be swollen. Abnormal blood levels of urea-N, creatinine and myoglobulin were noted when she was admitted. It appeared that the delayed APTT and PT were caused by acquired low activity of Xa induced by the snake venom. Subsequent to the start of hemodialysis, she was gradually restored, and at the same time, APTT, PT and serum myoglobulin improved to normal levels. In the event of acute renal failure induced by mamushi viper venom, temporary hemodialysis is believed to be indicated until uremic symptom disappers.

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We investigated the chemical features of diet-induced milky ascites in patients receiving chronic CAPD therapy. Milky chylous ascitic fluid taken from these patients was concentrated 10-fold using an ultrafiltration membrane, and its chemical composition was compared with that of CAPD patients with acute peritonitis and ordinary CAPD patients without any symptoms. As a result, the milky chylous ascitic fluid was found to be rich in total protein, albumin, total lipids, total cholesterol and B lipoprotein. Triglyceride levels, however, were higher than those of CAPD patients with acute peritonitis. Our data suggest that mass leakage of proteins and lipids is seen in CAPD patients with diet-induced milky ascites and that this gives rise to milky peritoneal dialysates.

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On-line hypertonic hemofiltration using high-performance membranes (F-80: Frezenius) was performed on a patient with myoglobinuric acute renal failure in order to eliminate not only uremic waste products but also nephrotoxic myoglobin. When admitted to our hospital, the patient was comatose with cerebral hemorrhage diagnosed by brain CT. Laboratory data on admission were as follows: Serum myoglobin 28, 900ng/ml, BUN 50, serum creatinine 3.9, uric acid 18.9mg/dl, markedly increased GOT, LDH, and CPK. On-line hemofiltration was started on the second hospital day. Substitution fluid was made from bicarbonate dialysate Kindaly AF-1 (Fuso Pharmaceutical Co., Ltd.) and supplied by personal dialysate supply system DBB-22 (Nikkiso Co., Ltd.). Hemofiltration was controlled by a plasma exchange system KM 8800 (Kurare Co., Ltd.). Electrolyte concentrations of the substitution fluid were as follows: Na 160, K 2.5, Mg 1.5, and bicarbonate 30mEq/l. Hypertonic fluid was pre-scribed for prevention of brain edema. Filtration speed was 4.8l/hr. Elimination of myoglobin was 10.8mg per hemofiltration procedure. Reduction of myoglobin was 55% and in the case of BUN, creatinine and uric acid, 50 to 70%. The patient had no complaints, and blood pressure was stable during hemofiltration. After 6 repetitions of on-line hypertonic hemofiltration, his renal function recovered.
On-line hypertonic hemofiltration using high performance membranes and bicarbonate substitution fluid proved excellent in compromized acute renal failure.

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We compared the life activities of patients with diabetes mellitus who were blind (DM-blind group, n=4), those who were not blind (DM-non-blind group, n=6) and those without DM (non-DM group, n=27) using a pedometer (Mampo Meter^®). The patients in the DM-blind group showed significantly fewer steps per day than patients in the DM-non-blind and non-DM groups. The body weight gain during successive dialysis (BW gain) was larger in the patients in the DM-blind group than in those in the other two groups. Nursing problems such as limited daily activities, low self-confidence and poor control of BW gain were more marked in patients in the DM-blind group than in those in the DM-non-blind and non-DM groups.
Six patients in the DM-blind and five patients in the DM-non-blind group were given exercise conditioning using a pedometer for 9 months by the methods previously described. After 3, 6 and 9 months of training, steps per day had increased from 1, 200±357 (mean±SEM), to 2, 330±705, 3, 720±1, 551 and 3, 770±1, 511, respectively, on dialysis days, and from 1, 520±317 to 2, 950±673, 4, 120±1, 475 and 4, 000±1, 503 on non-dialysis days in patients in the DM-blind group. In patients in the DM-non-blind group, steps per day increased from 4, 380±1, 603 to 5, 050±1, 959, 6, 290±2, 794 and 4, 950±1, 868 on dialysis days, and from 5, 267±1, 914, 6, 822±2, 326, 10, 001±5, 749 and 9, 139±5, 151 on non-dialysis days. Steps per day did not increase in either group after 6 months.
In the DM-blind group, after 6 and 9 months, CTR decreased from 54.8±4.0% (mean±SD) to 52.9±3.4% and 50±4.7%, respectively, during training. There were no significant changes in the dose of laxatives, degree of BW gain, Ht, total cholesterol and HbA₁ after the training course in either group. However, many benificial effects on physical and emotional status such as regained confidence in physical strength, improved defecation and onset of sweating were noted in many patients in both groups. Moreover, ADL activities were remarkablly increased in patients in the DM-blind group. Although DM-blind patients had limited activities, restricted life style and poor self-control abilities, exercise conditioning using a pedometer might be able to change their life style for the better.

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We studied the relationship between Mg content and other nutrients in the diet, as well as Mg balance, in patients on chronic continuous ambulatory peritoneal dialysis (CAPD) therapy. Mg content in the diet, which was diluted with ion-free water, homogenized, and supplemented with H₂SO₄ and HNO₃, was measured by the Xylidyl blue method, Na and K by flame photometry, and Ca by fluorophotometry. The results obtained were calibrated per 100kcal diet, and correlation coefficients were analyzed statistically.
Results: The Mg content of the diet was correlated with Ca, P, Na and protein content but not with K content. In CAPD patients, Mg intake was correlated with serum Mg levels, and serum Mg levels were correlated with Mg excretion into peritoneal dialysates. However, Mg excretion was not correlated with Mg intake. This increased Mg intake might be the cause of hypermagnesemia in CAPD patients.

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A 62-year-old diabetic male patient with angina pectoris and chronic renal failure developed massive hydrothorax 8 months after starting a program of continuous ambulatory peritoneal dialysis (CAPD). The pleural aspirate showed a raised concentration of glucose with a low concentration of protein. After ^99mTc-Sn-colloid was administered intraperitoneally with 2 liters of dialysate, high radioactivity was soon detected in the right pleural cavity, suggesting that hydrothorax was caused by trans-diaphragmatic leakage of the dialysate. Although hydrothorax resolved following the cessation of CAPD, angina attacks, which had remitted under CAPD, began to occur frequently on the days of hemodialysis. This suggested that CAPD is more suitable than hemodialysis for patients with angina pectoris, because it provides stable cardiovascular status.

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Total parathyroidectomy and autotransplantation of parathyroid tissue (PTX-AT) is reasonable therapy for patients with renal osteodystrophy (ROD) resistant to conservative therapy. PTX-AT were performed on 31 hemodialysis patients in our hospital. Two patients were followed up more than 4 years after surgery, and 16 patients were followed up more than 2 years. Serum Ca decreased rapidly after surgery but was maintained by Ca replacement therapy, and serum P decreased after PTX-AT, however, gradually increased and attained preoperative levels one year after surgery. Serum C-PTH decreased immediately after surgery and remained at low levels in most patients. Elevation of C-PTH (>5ng/ml) after surgery occurred in 7 patients. One of the 7 patients had recurrence in autotransplanted parathyroid tissue, 4 had recurrence in residual parathyroid, and 2 had no signs of recurrence in imaging studies. The skeleton was examined radiologically before and after surgery. Salt-and-pepper appearance of the skull and tuft-resorption of the finger bones improved markedly in 67% and 74%, respectively. However, the rugger jersey appearance of the spine improved in only 43%. The metacarpal index increased significantly from 47.1% to 51.1%, and it featured an increase in cortical bone. On the other hand, progression and no change in vascular calcification were found in 14 of the 16 patients after PTX-AT. One patient died of myocardial infarction in spite of radiological improvement in the bones. PTX-AT is considered effective therapy for ROD in hemodialysis patients, however, it cannot be expected to improve cardiovascular calcification.

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To clarify the causes of gastric mucosal lesions in patients with chronic renal failure, the incidence and location of mucosal lesions in the stomach were investigated endoscopically in patients on maintenance hemodialysis treatment (HD patients; n=137). Serum HCO₃^- concentration (n=66), gastric mucosal blood flow (GMBF; n=46) and the presence of Campylobacter pylori (n=23), which has been claimed to be related to certain gastric lesions, were also investigated. Erosive gastritis, gastric ulcer and acute gastritis were the main source of the lesions in the HD patients and were mainly localized in the gastric antrum. Acute gastritis lesions were also found in the gastric body (66.7%), except the antrum. Serum HCO₃^- and GMBF in the upper body greater curvature of HD patients were lower than in healthy controls, while the rate of detection of Campylobacter pylori was 43.5%, with no significant differences.
As a result, it has been suggested that deficiency of such gastric protective factors such as mucosal HCO₃^- secretion and GMBF may contribute to the occurrence of gastric lesions in chronic renal failure.

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