The left ventricular (LV) diastolic dysfunction, as well as systolic dysfunction, has been considered to play an important role in the pathogenesis of the cardiac failure in chronic hemodialysis (HD) patients.
To determine whether HD patients have impaired LV diastolic performance, we evaluated the LV diastolic function using pulsed Doppler echocardiography in 13 HD patients (HD group: 5 males, 8 females, mean age 55±9 years) and in 6 healthy subjects (control group: 4 males, 2 females, mean age 48±11 years). The transmitral velocity pattern has two wave components: one in the rapid filling phase (R wave) and the other in the late diastolic phase (A wave). The peak rapid filling velocity (R), the peak atrial filling velocity (A), and the ratio of R to A (A/R) were measured from the velocity pattern. Since the transitral velocity pattern is affected by LV diastolic function and the cardiac preload, it was quite important to obtain an accurate parameter for the volume status. For this, we applied a Swan-Ganz thermodilution ejection fraction/volumetric catheter during HD in 5 patients, and the right ventricular end-diastolic volume index (RVEDVI) was calculated using the thermodilution washout curve.
The A/R ratio was significantly higher in the HD group than in the control group (0.90±0.09 vs 1.21±0.30, p<0.01). In the HD group, R was significantly reduced from 43.5±9.9 to 37.0±8.0cm/sec after one session of HD (p<0.01). ΔR was positively correlated with the reduction of body weight. Since RVEDVI showed a higher correlation coefficient with cardiac index than RAP or PCWP in the right ventricular hemodynamic studies, RVEDVI seemed to be the best parameter for the cardiac preload. In HD patients, there was no statistical significance between ΔRVEDVI and ΔR.
These findings suggest that HD patients may show impaired left ventricular diastolic function even if the changes of preload during HD is taken into consideration.

View full abstract

To study the clinical significance of complement changes in chronic hemodialysis patients with insulin-dependent diabetes mellitus (IDDM), complements (CH50, C3, C4) and the C3 breakdown products C3d were measured. And to detect complement activating factors, of the circulating immune complexes (CIC) was measureed. The diabetic subjects were divided into four groups: Patients without complications (F, n=9), with nephropathy (DN, n=10), under hemodialysis (DHD, n=10), and normal healthy controls (N, n=42). All of the diabetics belonged to IDDM.
Results: 1. Complements (CH50, C3, and C4) in the three groups of diabetics showed higher levels than those in group N except C3 of group DHD. The C3d was significantly higher in both groups DN and DHD than in group N. From these facts, these values in group DHD may be affected by complement changes in the original diseases. 2. The CIC in group F, DN, and DHD was significantly higher than those in the normal subjects. Also the values of CIC in DHD were more elevated than those in group F. So it appeared that the increase in CIC may be related to the progression of diabetic nephropathy. 3. A significant correlation between CIC and C4 (r=-0.676, p<0, 05) was observed in group DHD.
This indicated that the classical pathway of the complement system with CIC was activated in group DHD.

View full abstract

A probe (2mm in diameter) was inserted through the CAPD catheter exit site, and the longest distance covered by the catheter was defined as “downgrowth” (“DGR”). Then the downgrowth (DGR) was actually measured in 4 cases in surgery. In 3 cases free from infections, DGR (7, 10, 10mm) almost agreed to “DGR” (7, 12, 8mm).
In 47 cases (at 27.3±14.0 months after initiation of CAPD), “DGR” was 10.5±4.7mm. “DGR” was not correlated with sinus tract (ST) and the duration of CAPD. When these cases were divided by the length of ST into under-30mm (23.1±5.4mm, n=22) and over-31mm groups (57.0±23.7mm, n=25), “DGR” was significantly shorter in the former groups. There was no correlation between “DGR” and the site of exit. “DGR” was markedly lengthened when exit infection was present, which suggested that the tissue around the catheter became fragile by infection.
The DGR of the CAPD catheter was clarified by the measurement of “DGR”.

View full abstract

Left ventricular function in 57 dialysis patients, of whom 15 showed dialysis hypotension and the other 42 had no hypotension episodes during dialysis, was studied by M-mode and palsed Doppler echocardiography. Mean ages of the hypotension and non-hypotension groups were 52.0±14.0 and 49.5±11.8 years, respectively. The mean dialysis duration of the hypotension group, 190.7±45.3 months, was significantly longer than that of the non-hypotension group, 142.7±82.0 months (p<0.05). The ratio of the peak atrial velosity (A) and early peak diastolic velosity (E) of the hypotension group, 1.3±0.4, was significantly higher than that of the non-hypotension group, 1.0±0.4 (p<0.05).
There was no correlation between diastolic dysfunction and peripheral blood counts or serum biochemical parameters. According to the results of multiple regression analysis, in which A/E was set as the criterion variable and explanatory variables were serum β₂-MG, increased body weight, CTR, IVRT, LVEF, LA, HD duration, age and serum Cr, serum β₂-MG and age appeared to have some influence on A/E.

View full abstract

We determined the blood concentrations after administration of cefuroxime (CXM) in patients on hemodialysis (HD) and conducted a pharmacokinetic study. This paper is a report of our findings.
The subjects are 24 HD patients. CXM 1.5g (dissolved in 50ml of saline solution) was administered by intravenous drip infusion taking 30 minutes during the period of non-HD and blood was collected over the time in 18 HD patients [HD (-) group]. In 6 other patients, the same test was performed during HD [HD (+) group].
The blood level in the HD (-) group was as follows. 0.5h after the start of drip infusion (immediately after the end of drip infusion): 112.9±32.2, 1.5h: 97.1±27.6, 35h: 81.4±24.2, 6.5h: 77.1±19.8, 8.5h: 70.9±15.8, 24.5h (24 hours after the end of drip infusion): 27.5±8.4μg/ml
The blood level in the HD (+) group was as follows. 0.5h after the start of drip infusion: 76.9±24.9, 1.5h: 39.6±3.6, 3.5h: 23.8±6.5, 4.0h: 19.7±5.3μg/ml
According to the results of pharmacokinetic analysis, the HD (-) group showed the T1/2: 12.2h, Cmax: 106.2μg/ml AUC (0→4h): 363.8, AUC (0→24h): 1, 405.4μg·h/ml, against T1/2: α phase 0.07, β phase 2.58h, Cmax: 76.9μg/ml, AUC (0→4h): 143.6μg·h/ml in the HD (+) group.
CXM is excreted from the kidney. In our studies, it was confirmed that excretion of CXM from blood was delayed in HD patients and that the CXM was eliminated by HD.
According to a simulation based on a 7-day consecutive administration, results of analysis showing that intravenous drip infusion of CXM in a dose of 1.5g/day is effective and safe were obtained in patients with renal failure who are in such a condition as to undergo HD once every two days.

View full abstract

A tolerable dose of cis-diamminedichlorolatinum (II) (cisplatin) is often limited by its adverse effects. In order to decrease the systemic exposure to cisplatin and increase its regional delivery, we used hemodialysis to try to remove cisplatin from the blood following its first passage through the tumor.
Patients with gynecologic malignancies were observed and the adverse effects were compared between the treatment with intraarterial cisplatin infusion into the internal iliac artery and the combination treatment with hemodialysis.
The blood of the inferior vena cava, which carried the highest concentration of cisplatin, was aspirated through a catheter in the femoral vein and returned to the superior vena cava after the removal of cisplatin. Hemodialysis was started just before the cisplatin administration and was continued for 60 min after completion of the infusion.
In the cases infused with 100mg of cisplatin, the systemic area under the time-concentration curve of nonprotein-bound cisplatin was reduced by 44% by combining hemodialysis, and the maximal serum cisplatin concentration (C_max) was reduced. The increase of urinary N-acetyl-β-D-glucosaminidase and β₂-microloblin excretion, frequently observed after cisplatin administration, was also suppressed by the combined therapy. Furthermore, in the cases infused with 200mg and 250mg of cisplatin during hemodialysis, C_max decreased to the same level as in the 100mg infusion alone and no severe systemic toxicity occurred when the combined therapy was used.
In conclusion, intraarterial infusion under hemodialysis can greatly reduce cisplatin exposure and allow an increase in the dose of cisplatin while maintaining tolerable systemic exposure.

View full abstract

Bone mineral content (∑GS), bone mineral density (μ′) and the second moment of area (I) were measured by the MD/MS method in 87 patients on maintenance dialysis. The relation of these indexes with age, sex, number of years of dialysis and bone metabolism-relate indexes were studied. Of these 87 patients, 64 who could be followed up for three years or longer were divided into three groups; I: parathyroidectomized (PTX); II: calcitonin+1 α-(OH)-D₃; and III: 1 α-(OH)-D₃ alone. Group III was further divided into three subgroups according to the total dose of drug given for three years: IIIa: ≥800μg; IIIb: 300-800μg; and IIIc: 300μg. The changes in ∑GS, μ′ and I were followed for three years and the therapeutic results were evaluated.
The ∑GS and μ′ were decreased with aging. This trend was specially marked in women. I was found maintained even in aged subjects. The ∑GS and μ′ decreased age-relatedly. There was a significant negative relation between the ∑GS and serum level of AI-P, as well as PTH. In group I, the ∑GS and I were remarkably improved in many patients, and the PTX was judged to be effective. However, in some patients, the μ′ decreased, which suggested a tendency to osteomalacia.
In group II, ∑GS, the μ′ and I increased, and the use of calcitonin and 1 α-(OH)-D₃ in combination was thought to be useful therapy. In group IIIa, the ∑GS, μ′ and I were maintained, but, in group IIIb and IIIc, the ∑GS and μ′ tended to decrease, and this suggested that a sufficient dose of 1 α-(OH)-D₃ was necessary to maintain bone mineral content.
The ∑GS, μ′ and I reflected the differences in therapeutic effect among these treatments for renal osteodystrophy. Therefore the MD/MS method was judged as useful to assess bone status including bone mass and bone strength in patients on dialysis.

View full abstract

We studied nine patients resuming dialysis after loss of a renal transplant received when they were being maintained on dialysis. Results of clinical tests before transplantation and after the loss of the graft were compared, and the attitudes of the patients toward the possibility of a second transplantation and about resumption of dialysis were also investigated. The patients were fairly well controlled by dialysis.
Erythropoietin was needed by seven of the patients. Patients receiving steroids when dialysis resumed often developed infections. Results of tests such as blood urea nitrogen, serum creatinin, red blood cell count and hematocrit value were not significantly different after the reintroduction of dialysis. Because of the erythropoietin, hematopoietic functions after the resumption of dialysis may have been lower than that before transplantation. Four of nine patients are willing to reconsider a second transplantation, but three of the four specify that they will consent only if the technique of transplantation is improved. Only one patient hopes for a second transplantation without reservations. This patient returned to hemodialysis three years after transplantation. At first, hemodialysis was scheduled irregularly, every seven or ten days, and this schedule gradually became more frequent and regular. Better methods for resumption of dialysis are needed.

View full abstract

Recently, the cardiovascular mortality rate has increased in hemodialyzed patients. We evaluated the role of blood pressure in determining the prognosis in dialyzed patients. In 195 patients (123 men and 72 women; mean age, 54±1 years), who were introduced to hemodialysis therapy in the National Cardiovascular Center between 1977 and 1987, the relationship was studied between blood pressures in both the introduction and maintenance phases and the surviving or death on January 1990. The age was higher (61±2 vs 50±2 years), the occurrence of diabetic nephropathy higher, and systolic blood pressure higher in both the introduction (178±4 vs 167±2mmHg) and maintenance (165±4 vs 147±2mmHg) phases in 46 patients who died within 3 years after starting hemodialysis than in 132 patients who survived more than 3 years. But there were no significant differences in diastolic blood pressures in either the introduction or maintenance phase between the two groups of patients. When diabetic nephropathy was excluded, only systolic blood pressure in the maintenance phase was significantly higher in the death group than in the surviving group. Therefore, based on the systolic blood pressure in the maintenance phase, patients were divided into two groups (HT group: ≥160mmHg and NT group: <160mmHg), and the cumulative survival rate was compared. Whether all patients, only patients with diabetic nephropathy, or those without diabetic nephropathy were examined, the survival rate was higher in the NT group than in HT group. The patients were also divided into the following three groups based on the changes in systolic blood pressure from the introduction to maintenance phase: HT-NT group whose blood pressure was higher than 160mmHg at the start, but was reduced below 160mmHg in the maintenance phase; HT-HT group whose pressure was higher than 160mmHg in both introduction and maintenance phases; and NT-NT group whose pressure was below 160mmHg in both phases. The cumulative survival rate in the HT-NT group was significantly higher than in the HT-HT group, and was as high as in the NT-NT group. Our results indicate that systolic blood pressure in the maintenance phase, corrected by hemodialysis, is important in determining the prognosis of hemoialyzed patients.

View full abstract

Pravastatin sodium (Mevalotin^®), an HMG-CoA reductase inhibitor, was administered to 11 diabetic (DM) and 22 non diabetic (non-DM) patients under regular hemodialysis who showed a high plasma total cholesterol (TC) level (≥220mg/dl) and/or low HDL cholesterol (HDLC) level (≤30mg/dl). They were followed every 4 weeks up to 24 weeks by measuring the plasma lipids level. A significant reduction of IC and LDLC, 19% and 27% each, appeared after 4 weeks' intake of Pravastatin at 10mg/day. These levels had been kept low up to 12 weeks, when they recovered to the starting level by the interruption of the medication, and decreased again by the readministration. HDLC showed a significant but transient increase (12% at 4 and 8 weeks) only in the non-DM group. Triglyceride (TG) decreased significantly (25%) in the non-DM group but not in the DM group. These changes made the atherogenic index (AI: TC-HDLC/HDLC) decline (non-DM: 6.1→4.1, DM: 5.6→4.4).
A blood kinetic study of Pravastatin in 5 dialysis patients compaired with the data from 4 normal controls showed a similar level of Cmax (29.7 vs 35.4μg/ml) and a significant prolongation of Tmax (3.9 vs 1.5 hrs) and t1/2 (2.9 vs 1.7 hrs). However, the blood levels of Pravastatin at 12 and 24 hrs after intake were less than 5μg/ml both in the dialysis patients and the controls, suggesting no accumulation effect of this drug in chronic renal failure.
In conclusion, Pravastatin was proved to be effective in reducing IC, LDLC and AI in the dialysis patients. The possibility that this improvement of the plasma lipid profile may decrease the atherogenic complications among the dialysis patients has to be examined by long-term clinical observations.

View full abstract

Peripheral nerve conduction velocity (NCV) and short-latency somatosensory evoked potential (SSEP) were studied in patients with chronic renal failure undergoing dialysis-treatment.
Thirty four patients receiving intermittent hemodialysis due to chronic glomerulonephritis (CGN group), 7 patients receiving similar dialysis due to diabetic nephropathy (DM group) and 5 CAPD patients with chronic glomerulonephritis (CAPD group) were examined. Healthy normal groups consisted of 23 volunteers for NCV (C₁) and 10 for SSEP (C₂). The NCVs were measured in median (sensory), ulnar, tibial and peroneal (motor) nerves after resting in an artifical climate room and SSEPs were recorded at Erb's and Shagass points against Fpz after median nerve stimulation at the wrist.
The following results were obtained. 1. In all the CGN, DM and CAPD groups, NCVs were significantly delayed as compared with in the normal C₁ group. The grade of velocity slowing was more marked in the lower than in the upper extremities. 2. In all the CGN, DM and CAPD groups, N₉ latencies in SSEPs were significantly prolonged as compared with those in the normal C₂ group. 3. N₂₀ latency values in all of the patient groups were similarly prolonged. 4. N_9-20 latency differences were significantly prolonged only in the CGN group. 5. N_20-35 latency difference values were not significantly different in the patient groups as compared to the normal C₂ group. 6. In the CGN group, no significant correlation was found between either the respective NCV values or N₉ latency and the duration of hemodialysis. 7. In the CGN group, the respective negative correlations were noted between either N₂₀ latency or N_9-20 latency difference and the duration of hemodialysis.
This last finding may reflect normalization of central sensory conduction time in correlation with the duration of dialysis-treatment in renal failure patients.

View full abstract

Four years after making an antebrachial shunt, a 47-year-old man on hemodialysis was seen for progressive venous dilatation with pain on the left cervical and thoracic surface. Shuntgraphy disclosed left innominate vein stenosis. This stenosis was cosidered to be a primary lesion because he had no history of subclavian vein cannulation or mediastinal disease. After percutaneous balloon angioplasty (PTA), an expandable metallic stent (EMS) was placed in the stenotic innominate vein. Three months after this procedure, all symptoms disappeared without occlusion of his shunt. We conclude that the PTA with an EMS is useful to keep the patency of the intrathoracic vein stenosis on the shunt side.

View full abstract

We report a case of cecal perforation developed in a 47-year-old woman. She had been treated with hemodialysis for five years, because of renal amyloidosis secondary to rheumatic arthritis. Her blood pressure gradually decreased and her systolic blood pressure was 60 to 90mmHg when she entered the hospital. After two months of severe hypotension, she had a spontaneous perforation in the gastrointestinal tract and died. Autopsy revealed a perforation about 5mm in diameter in the antimesenteric area of the cecum. Systemic amyloidosis was found, but the infiltration of amyloid in the area of perforation, or in the vessels supplying the perforated area was mild. Judging from the clinical and autopsy findings, we suggest that the cecal perforation was caused by persistent hypotension.

View full abstract

A 45-year-old man who had undergone ambulatory total parenteral nutrition (Home-TPN) to control refractory multiple ulcers of the small intestine, progressed to end-stage renal failure as a result of secondary renal amyloidosis. The Home-TPN and maintenance hemodialysis have been kept in the following water balance: water intake with TPN was 1, 640ml/day, body weight gain between dialyses was 0.5kg, ultrafiltration during dialysis sessions was 0.8kg or less, and the serum electrolyte concentration was maintained within a normal range. However, a strict restriction of water intake resulted in low caloric intake (1, 173kcal/day) and intravenous lipid supplementation was needed during hemodialysis sessions. This case has been dialyzed for three years without major complications while at fulltime work.

View full abstract

A 56-year-old woman, maintained on hemodialysis for 6 years, was admitted for evaluation of a liver mass revealed by CT scan at an annual screening. Laboratory findings on admission were as follows: GOT 32 KU, GPT 20 KU, HCVAb (+), αFP 684ng/ml. On CT scan there was a low density mass, 4.8cm in diameter. She was diagnosed by liver biopsy as having primary hepatocellular carcinoma, grade 2. We decided that percutaneous intratumoral ethanol injection therapy (PEIT) was suitable because she had many risk factors such as arteriosclerosis and cardiovascular disorders. We performed PEIT six times. After the treatment we recognized the tumor as necrotic tissue without viable cells. The CT scan showed a calcification area in the tumor. After the treatment there was no evidence of recurrence or metastasis. The patient survives fourteen-months after the treatment.

View full abstract

The patient was a 78-year-old man with chronic renal failure. Hemodialysis was started in December, 1986. He received an expanded PTFE loop forearm fistula in February, 1990. Nine months after this intervention, he developed a swelling in the elbow region where the vascular anastomosis had been present. There was no tenderness, no fever and no pulsation. An angiography of the fistula showed no particular change. Serial observations demonstrated progressive increase of the size of the swelling. After 4 months, an exploration of the swollen site was undertaken. The arterial limb of the PTFE graft was embedded in a smooth cystic gray tumor approximately 3cm in diameter. The tumor was removed completely, leaving the graft undisturbed. The mass consisted of amorphous acellular material covered by a fibrous pseuomembrane. The diagnosis was perigraft seroma. It seemed that a condition of abnormally high blood flow (1, 000ml/min) and low hematocrit levels contributed to the developing perigraft seroma formation.

View full abstract