Abdominal ultrasonography was conducted on 610 hemodialysis patients from March 1983 to December 1988. The relationship between renal cell carcinoma and ACDK (acquired cystic disease of the kidney) was studied. Comparisons were also made of renal cell carcinoma in hemodialysis patients and non-hemodialysis patients. Renal cell carcinoma was found in 7 patients (1.15%). The rate of discovery was 19 times higher than in nonhemodialysis patients. In all patients, the resected tumors were small renal cell carcinomas of less than 3.7cm in diameter, which fell into early cancer of stage I by Rebson's classification. In 7 patients, ultrasonography revealed a mass that had an internal echo with clear boundary and could be readily differentiated from cyst, angiomyolipoma and hematoma. There was no difference between hemodialysis and non-hemodialysis patients regarding ultrasonographic findings, stage, growth and histological classification. Of these 7 patients, ACDK was found in 6. In view of the finding that the tumor was inside the cyst and that it was associated with chronic glomerulonephritis, which was likely to develop into ACDK, ACDK seemed to be one of the factors leading to renal cell carcinoma in hemodialysis patients. Therefore, abdominal ultrasonography is most suitable for screening for renal cell carcinoma and should be carried out at least once a year for early discovery.

View full abstract

Regardless of the physiological health of the individual patient and skill of the transplant team, successful kidney transplantation can be seriously undermined in a unfavorable environment. Twenty-nine living related donors, recipients and most of their family members were seen by a psychiatrist and a medical social worker preand postoperatively.
The donors consisted of 20 mothers (68.9%), 6 fathers, 2 younger sisters and one younger brother. Regarding the donor agreement, 12 donors (42%) decided willingly to donate, while 11 (38%) agreed at the request of the recipient or family relatives. The others consented after orientation by a nephrologist or at a friend's suggestion. Family coercion was observed in some cases where a “black sheep” donor sought improved recognition within the family system. In the preoperative stage, donors hoped to facilitate the recipient's recovery from chronic renal failure and their rehabilitation in the community. In the postoperative stage, all of them hoped for long-term kidney survival, with most of them wanting the recipient to retun to a normal life and enlightenment of the kidney bank. Psychological observations revealed a high incidence of anxiety and defence mechanisms about their forthcoming surgery. This occurred especially in donors who gave passive consent. Even after successful transplantation. 27% of the donors had various psychological conflicts with the recipient, and in 6 families psychological problems related to intrafamilial dynamics among close relatives were observed.
This study showed that special psychological care and support by social workers and psychiatrists was needed in cases where donors as well as recipients showed ambivalence, untoward anxiety, depression or disconcerting behavior, and also suggests that social workers, psychiatrists and nurses have to interact with complementary supportive intervention in the transplant unit care setting.

View full abstract

We report a case of secondary hemosiderosis in a patient undergoing CAPD who was successfully treated with intravenous deferoxamine (DFO) administration.
The patient, a 51-year-old male with chronic renal failure and a history of 4 years of CAPD after 5 years of hemodialysis, had suffered from severe anemia and had received over 30 liters of transfused blood during the initial 5 years. He showed general pigmentation, impotence and liver dysfunction during the past 2 years. His hematocrit was 18.9%, serum iron concentration was 405μg/dl, and ferritin was highly elevated to 8, 200ng/ml Furthermore, ultrasonography revealed a “bright” liver caused by the heavy iron burden.
Intravenous DFO admistration was started as iron chelation therapy. The optimal dosage of DFO was determined to be 1.5g two times per week, because iron continued to be excreted in the spent dialysate for almost 3 days after DFO administration.
This therapy, which continued for the 16 months from March 1987 to July 1988, lowered the serum iron, ferritin, GOT and GPT levels to their normal ranges, but was not effective for his anemic state. No drug toxicity appeared during this study.
We suggest that intravenous DFO administration (1.5g given two times per week) is effective and safe for secondary hemosiderosis in CAPD patients.

View full abstract

The efficacy of recombinant human erythropoietin (rEPO) was studied in 8 anemic children undergoing continuous ambulatory peritoneal dialysis (CAPD). A dose of 65-100U/kg of rEPO was given intravenously in 4 of the 8 children 3 times weekly for 8 weeks, and thereafter, the same dose was given once a week throughout the study. A dose of 50U/kg of rEPO was given in one child 3 times weekly for 4 weeks. This therapy was given in the remaining 3 children at a dose of 70-150U/kg once a week throughout the study. The mean interval of therapy was 39 weeks (range: 4-68 weeks). Iron replacement was done in all children. Red cell count, hemoglobin (Hb) value, and hematocrit (Ht) value significantly increased one week after the initiation of rEPO. The total mean values of Hb and Ht increased from 6.1g/dl to 9.4g/dl and from 18.2% to 29.3%, respectively, with therapy. An increase in Ht of more than 5% was observed 2 weeks after the initiation of rEPO in 6 children treated at a dose of 150U/kg or more per week. Dyspnea at exercise and loss of appetite improved in all children. None had any adverse effect, including blood pressure elevation. The present study indicates that rEPO is effective in the improvement of anemic children undergoing CAPD.

View full abstract

The effects of rEPO on anemia of predialysis pediatric patients was evaluated in this study. Ten male and 11 female children with chronic renal failure and peripheral blood hemoglobin concentration and hematocrit values under 8g/dl and 24%, respectively, were included in the study. Their serum creatinine levels ranged from 4mg/dl to 10mg/dl and creatinine clearance was under 25ml/min. The average age of the subjects was 11.0+/-1.2 years old. Original renal diseases were hypoplastic kidney (6 cases), nephrotic syndrome (3 cases) and others (12 cases). rEPO was injected intravenously at a dose of 50U/kg, 1-2 times per week for 4 weeks. When hemoglobin was increased 1g/dl or hematocrit 3%, the treatment was continued at the same dose for another 4 weeks. When anemia was not improved, the dose was increased to 100U/kg. A total of 81.0% of the patients benefitted from rEPO. During the treatment, renal function was improved in 9 of 19 cases, deteriorated in 9 and was unchanged in one. There was no significant relationship between original disease, age, sex and other parameters, and changes in renal function. There were no remarkable side effects except for hypertension in one patient.

View full abstract

Oral 1α, 25 (OH) ₂D₃ pulse therapy and conventional therapy were performed in 9 hemodialysis patients with secondary hyperparathyroidism. The times during which the patients underwent pulse and conventional therapies were divided into four periods. The first period was 86.3 days (20-160 days) for pulse therapy. The second period was 84.1 days (37-210 days) for conventional therapy, the third period was 79.6 days (44-120 days) for pulse therapy, and the fourth period was 53.8 days (30-80 days) for conventional therapy. Under pulse therapy, 4.0μg of 1α, 25 (OH) ₂D₃ was administered orally at the end of each dialysis session (twice a week). Under conventional therapy, 0.25 to 1.0 μg of 1α (OH) D₃ or 1α, 25 (OH) ₂D₃ was administered every day, During each therapy, CaCO₃ and Al (OH)₃ were administered to serve as phosphate binders.
A month after pulse therapy started, the serum C-PTH level had decreased and the pain in bones and joints had disappeared. A month after pulse therapy stopped and conventional therapy started, the serum C-PTH level had increased and the pain in bones and joints had recurred. The serum ALP level decreased during the first pulse therapy period and did not change significantly during the following conventional, pulse and conventional therapy periods.
The changes in the serum C-PTH level and in bone and joint pain suggests that PTH may be a pain activator. When the pain in bones and joints disappeared, the mean serum C-PTH level was 14.5ng/ml (n=13), a significantly high level.

View full abstract

α-human atrial natriuretic peptide (α-hANP) is released from the heart during atrial stretch (volume overload). We assessed the clinical significance of α-hANP in patients on maintenance dialysis. Subjects included 11 CAPD patients and 10 HD patients.
The following results were obtained; 1. Initial plasma α-hANP levels of HD patients were elevated when compared with those obtained in healthy subjects and CAPD patients. 2. There was a statistically significant correlation between plasma α-hANP levels and the size of the heart. 3. Plasma α-hANP levels fell during hemodialysis. 4. In HD patients, there was a statistically significant correlation between changes in α-hANP levels and changes in body weight. 5. In CAPD patients, there was a statistically significant correlation between ultrafiltration index and plasma α-hANP levels.
Plasma α-hANP seems to be a reliable parameter of the so-called dry weight in patients on maintenance dialysis. We consider that plasma α-hANP levels of less than 50ng/ml after hemodialysis and during CAPD would be a goad index suggesting that dry weight had been reached.

View full abstract

The influence of renal failure and hemodialysis on the anticoagulant effects of FUT was studied in 8 patients under going hemodialysis (HD group) and 5 healthy volunteers (Nr group). To determine FUT kinetics, serum concentration (by HPLC) and celite activated clotting time (ACT) were examined after 0.3mg/kg FUT administration. FUT showed very rapid and short action as an anticoagulant agent, with an effective serum level over 1, 580ng/ml.
FUT kinetics of the HD and Nr groups, respectively, were as follows: volume of distribution (Vd) 0.08±0.07/0.36±0.23l/kg; total body clearance (CL) 0.02±0.01/0.07±0.04ml/min/kg; elimination half lives (t1/2) 1.04±0.60/1.73±1.49min; elimination rate constant (Kel) 0.83±0.36/0.64±0.40min^-1. The HD group showed smaller CL and Vd (probably from A-V fistule), but shorter t1/2 and higher Kel than the Nr group.
These results suggest that there were no clinical differences in FUT kinetics between the HD and Nr groups.

View full abstract

In patients beginning regular hemodialysis (HD), psychological receptivity to HD may be an important factor in adjustment. In the present work, we studied how to support a smooth transition to regular HD and to improve the quality of life afterwards. Eighteen patients admitted to the hospital since 1987 were selected. The following psychological tests were administered when patients were introduced to regular HD and just before dischage to assess their psychological condition: The Social Adjustment Scale (SAS), Sentence Completion Test for HD Patients (D-SCT) and Manifest Anxiety Scale (MAS). With these results, changes in anxiety and in adjustment to HD from admission to discharge were evaluated. Adaptability to HD, self-control and human relations with their families were also studied.
According to the results just before discharge, patients were classified as follows. Group I (5 patients) included those who “adjusted” with a high degree of anxiety. Group II (6 patients), those who “adjusted” with a low degree of anxiety, were further divided into two subgroups: II-a, who remained in group II after admission, and II-b, who changed to group II after admission. Group III (7 patients) showed “escape” and a low degree of anxiety. Fink's theoretical model of crisis showed typical psychological steps of adjustment to HD such as from group III to II-b, from II-b to I and I to II-a, regarded as complete adjustment.
In conclusion, well-adjusted patients showed adaptability, good family relations and self-control. The important point in nursing may be “neutrality” and helping the patient adjust to and accept regular HD. This might help the patient to be more independent and reduce anxiety about HD.

View full abstract

Thirty-two cases of upper extremity venography in hemodialyzed patients before reconstruction of external or internal shunt were evaluated. Venography was compared with standard shuntgraphy as to its advantages and drawbacks.
Venography proved to be of excellent use in shunt reconstruction in that it provided information supplementary to that obtained in shuntgraphy or even more valuable information. Venography permits delineation of the entire venous system in the upper extremity and, in addition, sometimes yields information on regions surrounding the shunt, as is possible by shuntgraphy. It was considered important to maintain 30° flexion of the cubital joint and supination of the antebrachium and to use a 35×43cm film to facilitate upper extremity venous system interpretation.
We encountered no complication or adverse reaction in any case in the present study.

View full abstract

1. Anatomical snuffbox arterio-venous fistula was established in 73 patients who had been newly placed on hemodialysis, and the post-operative course was analyzed for 34 months. Fifteen shunts were obstructed (21%). Early (within twelve weeks following operation) and late obstruction were observed exclusively in patients with diabetic nephropathy.
2. The blood flow wave pattern was recorded by the supersonic Doppler method. The change in blood flow with tabaciére shunt was studied for one week after the operation. The average amount of blood flow was about 200ml/min, which was judged to be satisfactory for hemodialysis patients with diabetic nephropathy. No special wave pattern, however, was observed in patients with diabetic nephropathy.

View full abstract

Once-a-week hemodialysis is increasingly used because it maintains residual renal function without a marked change in life habits. Hemodialysis was introduced once a week in an elderly patient who could not walk because of left hemiplegia, and who had previously refused hemodialysis. The patient was observed for one year. She was an 82-year-old woman who had trouble as an inpatient because of her egocentric personality. During the 3-year course, urine volume was maintained but renal failure gradually exacerbated. Although she initially refused hemodialysis, she was persuaded to receive it once a week. Since she could not record them herself, her helper was instructed to record water intake, food intake, urine volume and somatic symptoms, and guidance was given to the patient by the doctor in charge on every hemodialysis day. Up until her sudden death due to acute myocardial infarction one year later, the patient had no severe complications and could continue to undergo hemodialysis without marked changes in her life style or her family's social life. This experience suggests that this therapeutic method is effective when good cooperation with family members can be obtained, and carefully thought-out instructions are given, even if the patient is elderly.

View full abstract

A 51-year-old male undergoing CAPD for 6 months was admitted because of right-sided hydrothorax with sudden decrease in net ultrafiltration and increase in body weight. No peripheral edema or evidence of inflammation were observed, and the concentration of glucose in the patient's pleural fluid was higher than in his blood suggesting the transfer of dialysis solution into the pleural cavity. To confirm our presumed diagnosis, ^99mTc-MAA was administered intraperitoneally, and traps-diaphragmatic leakage was clearly demonstrated. Instillation of autologous blood after drainage of the pleural effusion by thoracentesis failed to correct the condition, however, pleurodesis with autologous blood combined with short-term interruption of CAPD and subsequent use of a small exchange volume was effective. Although there were no side effects, we need to conducta follow-up, because permanent adhesion of the pleural layers may not have been achieved.

View full abstract