Although the accumulation of β₂-microglobulin (β₂-MG) appears to play a key role in the pathogenesis of hemodialysis related amyloidosis (HRA), the curious predilection of β₂-MG-amyloid (Aβ₂-MG) deposits for bone and joints is unexplained. The present animal study was undertaken to clarify whether the β₂-MG-Aβ₂-MG deposits are the cause or merely the results of arthropathy.
Eighteen heminephrectomised, male inbred DBA/1J mice were divided into 3 equal groups of 6 animals. In groups 1 and 2, arthritis was produced by intradermal injection of an emulsion of bovine collagen type II (C-II) and complete Freund's adjuvant with a subsequent i. p. booster injection of C-II. Group 3 mice did not receive C-II treatment and served as controls. After collagen induced arthritis (CIA) had developed in groups 1 and 2, human urine derived β₂-MG, 100 to 300μg, was given by s. c. injection to group 1 for up to 10 days. Human β₂-MG was also given to 6 mice without CIA in group 3 using the same schedule.
Regardless of the presence of CIA, human β₂-MG was deposited predominantly in the bone marrow, as well as synovia, of the human β₂-MG treated mice in groups 1 and 3. On the other hand, group 2 mice which had not been given human β₂-MG had no deposits of β₂-MG. Aβ₂-MG deposits were not seen probably because of too short observation period.
These findings suggest that if β₂-MG levels are high, β₂-MG is deposited in the articular structure as a primary event.

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Recently, it has been reported that there are considerable difficulties in diagnosing ischemic heart disease by ECG alone in patients on HD and CAPD. This study was designed to evaluate the diagnostic values of exercise thallium-201 myocardial scintigraphy as compared with ECG examination alone in patients with chronic renal failure. The subjects were 26 patients with chronic renal failure, including patients being treated with HD and CAPD, and 7 normal persons who served as controls. Exercise thallium-201 myocardial scintigraphy was performed according to a multistage bicycle ergometer exercise test.
Exercise duration times were shorter (p<0.001) and maximum attained heart rates lower (p<0.05) in the HD group than in controls. Since exercise capacities were reduced in the dialysis patients, there were considerable difficulties in diagnosing ischemic heart disease by ECG alone. In our 26 patients, 15 cases (57.7%) had left ventricular hypertrophy, 5 cases (19.2%) had manifestations of ischemic heart disease, and 4 cases with abnormal ECGs had no abnormal findings on exercise thallium-201 myocardial scintigraphy. Thallium wash out rates were higher (p<0.001) in the chronic renal failure group than in the control group, and a significant negative correlation (r=-0.70, p<0.001) was found between thallium wash out rates and Ht values.
Exercise thallium-201 myocardial scintigraphy was more accurate than ECG examination and also could be performed repeatably without invasion. These results indicate that exercise thallium-201 myocardial scintigraphy is a valuable diagnostic method for ischemic heart disease in patients with chronic renal failure.

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From July 1989 to September 1990, 6 cases of Paraquat poisoning were observed in Kurashiki Central Hospital. All 6 were treated with gastric lavage, forced diuresis and infusions (7-10l/day), direct hemoperfusion and continuous intestinal lavage with Golytely for 72-96 hours. Five cases were cured without any squelae. In these patients, urine was checked every 3 hours and Paraquat was no longer detectable in the urine within 16 hours of the patient having taken it. One case who took about 400ml of a 24% solution of Paraquat lapsed into multiple organ failure despite early initiation of treatment. The key point of treatment of Paraquat poisoning is complete removal of Paraquat from the body as soon as possible, but complete and rapid intestinal lavage is difficult because plasma electrolyte concentrations can change easily. Golytely can wash the intestine completely in a short time without causing imbalance of plasma electrolyte concentrations and is therefore useful for safe treatment of Paraquat poisoning. If the intestinal mucosa is broken down over a wide area by Paraquat, however, Golytely may lead to absorption of large amounts of water. Thus, the patient's water balance has to be attended to carefully during therapy.

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In order to clarify abnormalities of blood coagulation and fibrinolysis in hemodialysis patients, some new molecular markers for hemostasis and thrombosis, including α₂-plasmin inhibitor·plasmin complex (PIC), fibrinfibrinogen degradation products (FDP-E, FDP D-dimer), thrombin·antithrombin III complex (TAT) and soluble fibrin monomer complexes (SFMC), were examined in comparison with normal subjects. Thirty four maintenance hemodialysis patients, 17 males, 17 females, average age 61.1 years, average hemodialysis period 4 years 5 months, were investigated. PIC, FDP-E and FDP D-dimer were significantly higher in the hemodialysis patients than in normal subjects. Similarly, TAT and SFMC were significantly higher in the hemodialysis patients. The effects of recombinant human erythropoietin on blood coagulation and fibrinolysis were also evaluated in 18 maintenance hemodialysis patients. Each patient received erythropoietin injections for about 3 months. PIC, TAT and SFMC were significantly higher in the hemodialysis patients after the administration of the erythropoietin as compared to pretreatment levels. These results suggest that the abnormalities of coagulation and fibrinolysis exist in maintenance hemodialysis patients, and moreover, that erythropoietin enhances these abnormalities after the patients' recovery from anemia.

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Since nosocomial infection with MRSA is common, a preventive system is essential for any hospital dialysis center. This study was undertaken to investigate the annual number of MRSA strains isolated from clinical specimens from 1980 to June 1991 in our surgical ward and dialysis center, and our treatment and system for preventing nosocomial MRSA infection.
Isolated MRSA strains were first detected in 1981 and increased remarkably from 1985 on ward in our surgical ward. One hundred and eighty one strains of MRSA were isolated and 76 cases who developed critical infections. Among hemodialysis patients, an MRSA strain was detected first in a postoperative case in 1989. Cross-infections in the intensive care unit were subsequently recognized in acute renal failure and postoperative hemodialysis patients. After recovery from the critical infections, these patients received maintenance hemodialysis in our dialysis center and continued to have isolated MRSA strains. Intravenous administration of vancomycin for MRSA pneumonia in 3 postoperative hemodialysis patients cured their MRSA pneumonia.
We recommend intravenous administration of vancomycin, which is administered as 1.0 gram a day dose during two days and then in 0.5 gram doses after regular hemodialysis. Our system of prophylaxis against nosocomial infection with MRSA consists of hemodialysis in a private room, a gown technique and sterilization of hands and fingers with a rubbing alcohol sterilizer. Because there has been no evidence of nosocomial MRSA infection in our dialysis center, we are confident that our system is effective in preventing nosocomial MRSA infection in hospital dialysis centers.

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Plasma concentrations of human atrial natriuretic peptide (hANP) were measured before and after hemodialysis (HD) in 19 patients undergoing chronic HD. We examined plasma hANP concentrations before HD in 36 patients, then re-examined the same patients 1 year later to assess annual changes. Plasma concentrations of hANP had decreased significantly from 262±38pg/ml (mean±SE) to 164±19pg/ml after HD (p<0.001). There was a significant correlation (p<0.05) between changes in plasma hANP concentrations and decreased body weight during HD. Plasma hANP concentrations correlated significantly (p<0.01) with mean blood pressure. Plasma hANP concentrations in the second year increased significantly as compared with those of the first year (p<0.05). There was a significant correlation (p<0.001) between the plasma hANP concentration in the first year and that in the second year. These results suggest that plasma hANP concentration may serve as a control index of body weight and hypertension, and may be a prognostic indicator in patients receiving chronic HD.

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Continuous measurement of blood pressure is one of the most urgent problems to be solved in the effort to develop precise hemodialysis treatment. A new approach has been developed, based on analysis with an electric equivalent circuit of the patient's cardio-vascular system, and is presented here. The result of this analysis revealed a simple but useful relation between blood pressures measured at the dialysis circuit and those in the brachial artery. To put this observation to clinical use, a new dialysis circuit was designed so that the inlet of the circuit has an air-trap as well as an outlet side. The inlet air-trap should be rigid enough to withstand negative pressure due to suctioning of blood by the pump. The pressures at the two air-traps were measured and the mean brachial pressure was calculated for on-line display. The results of clinical tests were acceptable and had the advantage of being non-invasive.

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The case of a patient on regular hemodialysis, who underwent successful pheochromocytoma surgery after careful preoperative management is presented.
The patient was a 45-year-old woman who had been receiving regular hemodialysis for four years. Since April 1989 she had experienced paroxysmal hypertension with headache and nausea after dialysis, and abdominal computed tomography in March 1990 revealed a left-sided adrenal mass. The definite diagnosis of pheochromocytoma was made on the basis of clinical and laboratory examinations, and adrenalectomy was recommended.
Preoperative management, including the use of prazosin and body weight control, was carefully designed to prevent severe intra-and postoperative cardiovascular complications. Prazosin was given at an initial dose of 0.5mg/day, and increased there after to 20mg/day prior to surgery. In order to increase intravascular volume, she gained 3kg in body weight. The deterioration of cardiovascular and respiratory status was prevented by these preoperative maneuvers, and surgery was performed without significant complications except for a rapid rise in blood pressure during resection of tumor.

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A 73-year-old female, who had complained of epigastric pain and vomiting, was diagnosed as having erosive gastritis at another facility. A short time later she developed facial edema and acute renal failure was diagnosed. She was referred and admitted to our hospital to receive hemodialysis. On admission she had acute cholecystitis and hemolytic uremic syndrome (HUS) due to microangiopathic hemolytic anemia, thrombocytopenia and acute renal failure was diagnosed. After admission she was treated with hemodialysis for acute renal failure and antibiotic therapy for acute cholecystitis. The renal function, hemolytic anemia and thrombocytopenia improved. She recovered from HUS, although she was not treated with anticoagulant, antiplatelet therapy or plasmapheresis. Endotoxin produced by gramnegative rods was suggested as the casual agent of HUS. Antibiotic therapy for acute cholecystitis was effective in improving HUS.

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A 53-year-old man, who had been undergoing hemodialysis for 12 years, complained of epigastralgia and bilateral shoulder pain. He had a history of bilateral uveitis (ocular sarcoidosis) and paresthesia and weakness of the extremities of unknown origin successfully treated with steroid pulse therapy. He rapidly grew delirious and somnolent. Laboratory findings were as follows: calcium 6.9mEq/l, angiotensin converting enzyme 55.4mU/ml. We suspected hypercalcemia as the cause of the disturbance of consciousness and treated with prednisolone and elcatonin. Daniel's biopsy of lymph nodes of the scalenus anterior muscle was performed and the specimen revealed sarcoidosis histopathologically. Our present case is the first case of sarcoidosis with hypercalcemia and disturbance of consciousness in a hemodialysis patient in the Japanease literature.

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The case of a 54-year-old Woman with Fabry's disease treated by CAPD is presented. She was admitted to our hospital complaining of nausea and pretibial edema. Laboratory studies on admission showed hyperazotemia, hyperkalemia and metabolic acidosis accompanied by marked cardiac hypertrophy. We made a diagnosis of CRF with hypertrophic cardiomyopathy and she was treated by CAPD. Meanwhile, her second son was admitted with proteinuria and renal biopsy was conducted, revealing a probable diagnosis of Fabry's disease. Deficiency of α-galactosidase A activity confirmed the diagnosis. The patient died of heart failure, 31 months after the first admission, and was autopsied. Autopsy revealed marked degenerative changes in muscle cells in small arteries of the kidney which might have been the etiology of the CRF. We report this case because relatively few cases have been reported world wide.

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A 58-year-old female was admitted to our hospital for fever, polyarthritis, pleuritis and pericarditis. She had noticed Raynaud's phenomenon at about age 30. Two years prior to admission, small painful ulcers were noted at the tips of the index fingers of both hands. Chronic hemodialysis was initiated by placement of a Brescia-Cimino arteriovenous fistula in her left forearm at another hospital 10 months before admission to our hospital. When she was first seen by us, sclerodactylia, digital bone absorption and pulmonary fibrosis were observed and a diagnosis of progressive systemic sclerosis (PSS) was made. The patient was treated with remarkable effect with prednisolone (30mg/day) and her symptoms gradually disappered. However, 3 months afer admission, painful digital ulcer of the left third finger apex appeared. Three months later, the same ishemic change also developed on her left small finger. After starting each hemodialysis therapy, pain, pallor and coldness of the left hand worsened markedly. These ischemic symptoms were considered to be the result of radial steal syndrome. This case indicates the importance of considering the type and site of arteriovenous fistula in hemodialysis patients with PSS.

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A 52-years-old woman was admitted for exacerbation of edema and severe azotemia. Her sodium (Na) concentration was as low as 123mEq/l on admission. Treatment with hemodialysis (HD) was started because of the progressing azotemia. Serum Na concentrations were 112 and 131mEq/l at the start and the end of the first HD, respectively. During the second HD 3 days after the first HD, athetoid involuntary movements (IVM) of the right upper and lower extremities suddenly occurred. The IVM tended to improve after interruption of HD but still appeared intermittently. Serum Na concentrations before and after the second HD were 127 and 138mEq/l, respectively. The neurological examination revealed saccadic eye movements and increased deep tendon reflexes. IVM disappeared after oral administration of clonazepam the next day, and did not recur even after discontinuing clonazepam on the ninth day. The MRI examination of brain after 40 days, failed to detect any abnormal findings in the pons and elsewhere. No remarkable abnormalities were found in electroencephalograms on the next day and two months later. We suspect that the cause of neurological symptoms in this case was due to the rapid correction of hyponatremia by HD. Since hyponatremia often occurs at the end stage chronic renal failure, the correction of the electrolyte disorder should be made carefully.

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