We have performed a total of 356 intravenous reinfusions of ascites in 91 cases of malignant ascites encountered at our hospital. These patients were refractory to treatment with various drugs including diuretics. Ascitic drainage by paracentesis was performed in another 30 cases.
The following findings were obtained: 1. Intravenous reinfusion of ascites was a more useful clinical therapy than drainage of ascites by paracentesis. 2. The therapeutic effect of intravenous reinfusion of ascites tended to be increased when it was combined with biological response modifiers (BRM) such as OK-432. 3. The combined administration of OK-432 with intravenous reinfusion of ascites was not so different between subcutaneous and intraperitoneal routes of administration. 4. The combination of anti-cancer agents with the intravenous reinfusion of ascites failed to improve the therapeutic effect. 5. Fever was the main side effect of this therapy. It was well tolerated with appropriate antipyretics.

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Thirty-six patients on chronic hemodialysis underwent emergency surgical operations at the Dialysis Unit, Tokai University School of Medicine, from July, 1976 to December, 1988. During 1988 there were such cases. We discuss these nine cases and the results obtained were as follows: 1. In cases requiring emergency surgery the preoperative blood urea nitrogen and creatinine levels were significantly higher and the blood HCO₃^- levels were significantly lower than in those cases undergoing elective surgery. 2. Postoperative complications included hyperkalemia and pulmonary edema in one case, obstruction of the A-V fistula in one case and a minor leak after gastrectomy in one case. There were no deaths. 3. During surgery, Solita T1^® was infused and postoperatively the intravenous infusions were mainly glucose solutions. Five of the nine cases had intravenous hyperalimentation. Measurments of central venous pressure were performed in five cases during surgery and in three cases postoperatively. 4. In eight of the nine cases, hemodialysis was performed the day after surgery. No heparin was used in three cases, and low dose heparin was used in five cases. There was no incidence of postoperative hemorrhage.
The results of the present study indicate that emergency surgery can be safely performed in patients on chronic hemodialysis.

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In renal failure patients on hemodialysis, various methods are used to measure PTH blood levels including cterminal PTH (C-PTH), (1-84) PTH (INS-PTH) and highly sensitive PTH (HS-PTH), but it is important to study the features of each method in order to gain a clear understanding of the pathological conditions of secondary hyperparathyroidism.
In the present study, these three methods were compared in chronic hemodialysis patients, and the following results were obtained. 1. HS-PTH showed a high correlation with INS-PTH and C-PTH (r=0.774 and 0.967), C-PTH showed a low correlation with INS-PTH in cases where INS-PTH≤120pg/ml (r=0.488). 2. In a comparison of the reproducibility at monthly intervals in the same patients without any changes in treatment, HS-PTH showed the smallest variations. 3. In cases which showed a gradual increase in C-PTH in the blood over one year of observation, INS-PTH showed higher values than HS-PTH. And in cases of a gradual decrease in serum C-PTH over the same period of observation, INS-PTH showed lower values than HS-PTH.

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From 1976 to 1989, we experienced 55 episodes of diagnosed fever of unknown origin (FUO) in 36 dialysis patients. Underlying causes of FUO were infection (18 episodes), collagen disease (1), and unknown (36). Infection included 10 episodes of tuberculosis, the most common cause of FUO, and 9 of the tuberculosis episodes were extrapulmonary. Thirty-one episodes (56.4%) of FUO appeared within the first year of maintenance dialysis. Thirteen episodes (28.9%) did not show leukocytosis or positive response to CRP in laboratory findings. Though the pattern of fever was intermittent or remittent, there was no pattern characteristic of any particular disease. We believe that some episodes involving fever below 33°C may indicate a disease which requires aggressive treatment. We suggest the immediate trial of antituberculosis therapy when antibiotic therapy is ineffective.

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CAPD was compared with hemodialysis in terms of the balance of Ca and phosphate. The high serum Ca level in CAPD limited the use of vitamin D and Ca carbonate. However, CAPD patients showed lower PTH and ALP levels than those on hemodialysis, as well as better bone parameters by microdensitometry. As a result, we considered that osteodystrophy is inhibited only within 4 years after the introduction of CAPD. The Ca balance has been negative even using dialysate at the present Ca concentration. In order to increase the dosage of vitamin D and Ca carbonate in the future, a low-Ca dialysate will be required. At present, 10% of patients require increased doses of vitamin D due to increased PTH. It is advisable to use low-Ca dialysate in these patients.

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Prolonged survival of vascular access is vital to trouble free dialysis. This study was designed to determine the factors affecting the patency of the vascular access. We reviewed our experience with 975 vascular access procedures (364 autogenous internal A-V fistulae, 211 PTFE internal A-V fistulae, 260 autogenous external shunts, 138 PTFE external shunts) in 316 chronic hemodialysis patients.
Whereas the cumulative patency rate for autogenous internal A-V fistulae was 65% at 3 years and 57% at 5 years, the patency rate for PTFE internal A-V fistulae was 31% at 3 years and 21% at 5 years. Autogenous internal A-V fistulae thus retained a significantly higher patency rate compared with PTFE internal A-V fistulae (p<0.001). Autogenous external shunts and PTFE external shunts had extremely poor results; patency rates were similar and about 20% at 1 year and about 10% at 2 years. We statistically analyzed the following variables; sex, age, causes of renal failure, diabetes mellitus, hypertension, hyperlipidemia, hematocrit and site of anastomosis. Multivariate analysis proved significantly poorer patency in older patients for autogenous internal A-V fistulae (p<0.01), and in patients with hyperlipidemia (p<0.01) or diabetic nephropathy (p<0.05) for PTFE internal A-V fistulae. Patients with more than 2 risk factors had a significantly worse patency rate for PTFE internal A-V fistulae compared with patients with less than 1 risk factor.
It has been definitely shown by this study that age, hyperlipidemia and diabetic nephroathy worsen the patency of vascular access. This study also suggests that the other factors may also affect the patency of PTFE internal A-V fistulae.

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Changes in atrial natriuretic peptide (ANP) concentration were compared in relation to accompanying changes in body weight (BW) and blood pressure (BP) in 10 diabetic (DM) and 10 non-diabetic (non-DM) hemodialysis patients during hemodialysis. ANP, body weight, ultrafiltration rate, BP and various hormones (renin, catecholeamines, angiotensin II, aldosterone) were measured before, at 2 hours and at the end of hemodialysis treatment.
Plasma ANP levels in the DM group were always higher than in the non-DM group during hemodialysis. The percent changes in BW and ANP, and BP values in the non-DM group obtained at 2 hours and at the end of hemodialysis were -2.1 and -26% and 166/90mmHg (2 hours), and -4.02 and -40% and 144/85mmHg (end), respectively. However, a more significant fall in ANP at 2 hours was observed despite the similar decrease in body weight in the DM group, the values of which were -2.1% in ANP and -42% in BW changes, respectively. The BP of the DM group at 2 hours was also lower (142/73mmHg).
The values of the DM group determined at the end of hemodialysis were not different from those of the non-DM group [-4.03% (BW), -41% (ANP) and 130/69mmHg (BP)].
No positive correlations between ANP and any of the hormones determined on the three occasions were demonstrated in either group.
Our results suggest that the differences observed in ANP concentration between non-DM and DM patients are a consequence of fluid loss. This would imply that some unknown factors are involved in changes in the ANP level during hemodialysis, particularly in DM patients.

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We report on a patient with rheumatoid arthritis (RA) who developed marked gastrointestinal symptoms after the start of dialysis for the treatment of systemic amyloidosis secondary to RA.
The patient was a 40-year-old woman who had been suffering from RA for about 10 years before she came to show increased urinary protein and renal dysfunction.
After the start of dialysis, gastrointestinal symptoms such as nausea and vomitting were persistent, and finally she developed repeated melena. Amyloidosis was suspected after gastro-and colono-fiberoscopy.
The bleeding could not be stopped, and one month after the start of dialysis, she died. Postmortem histological examination confirmed a definite diagnosis of amyloidosis type AA.
The initial signs of renal amyloidosis secondary to RA are thought to include an abrupt increase in urinary protein and renal hyofunction. The treatment should be tried as soon as possible after the diagnosis of amyloidosis is established by an early renal biopsy.

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Chronic ambulatory peritoneal dialysis (CAPD) is reported to be an effective treatment for chronic renal failure caused by primary amyloidosis.
Our case was a twenty-year-old Japanese male with progressive renal failure. Although hemodialysis was unsuccessful because of prominent hypotension and troubles with vascular access, CAPD was successful in improving his physical condition without any complications. During treatment an amyloid goiter appeared associated with severe hypothyroidism which caused myxedema coma. Replacement therapy with thyroid hormone brought about a complete remission.
We would like to emphasize the importance of thoroughly investigating thyroid function in the early stages of chronic renal failure.

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We tried nightly intermittent peritoneal dialysis (NPD), continuous cyclic peritoneal dialysis (CCPD) and NPD combined with continuous ambulatory peritoneal dialysis (CAPD) in a CAPD patient with membrane failure. The patient obtained satisfactory clearance of small solutes and net ultrafiltration volume without an increase of albumin clearance, and was able to continue on peritoneal dialysis by performing NPD combined with CAPD. However, long-term follow-up is required, because the increased number of dialysate exchanges required in NPD combined with CAPD may exacerbate peritoneal function earlier than in other methods of peritoneal dialysis.

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A patient maintained on chronic hemodialysis for 13 years had acute hemorrhagic necrotic pancreatitis. We performed peritoneal lavage with good results. Case history: A 48-year-old man started chronic hemodialysis in January 1971, and was admitted to an other hospital because of liver dysfunction occurring in October 1988. He had nausea and abdominal pain on July 4, 1989. At that time, the amylase level was 1, 586mg/dl and pancreatic swelling was observed on US. He was admitted to the emergencey center on July 6, 1989, and the kidney center of Tokyo Women's Medical College Hospital on the next day. He was given conscervative therapy.
We diagnosed severe acute pancreatitis by laboratory data, US and CT. We placed a PD catheter into Douglas' fossa and drained about 120ml of ascites, which was bloody and turbid. We diagnosed acute hemorrhagic necrotic pancreatitis and started peritoneal lavage. His symptoms improved greatly with several peritoneal lavages and exocrine isozymes. Amylase in blood and lavaged fluid decreased, but increased once in the hospital course. He was discharged with no complications on September 27, 1989.

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We experienced pontine hemorrhage in a patient on continuous ambulatory peritoneal dialysis (CAPD). The patient showed a successful clinical course with the same therapy after the hemorrhage.
This 48-year-old male started CAPD in June 1985, because of chronic renal failure due to chronic glomerulonephritis. He was maintained in a stable condition until December 27, 1988, when he was admitted to our hospital because of acute peritonitis. He developed pontine hemorrhage on December 31, 1988. We continued CAPD therapy as before while using glyceol and steroid to reduce brain edema. At about one month after the pontine hemorrhage, brain edema disappeared completely. He was able to eat at 4 months, his level of consciousness was clear at 6 months and he underwent rehabilitation at the same time. At the end of 8 months he started to walk, and on October 19, 1989, was discharged.
Cerebrovascular accidents in uremic patients are often fatal, with the prognosis of brain stem hemorrhage especially poor. Thus, in uremic patients complicated with cerebrovascular accident, CAPD can be considered a useful replacement therapy.

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A rare case of subcapsular liver hematoma due to severe peritonitis during CAPD is reported. A 24-year-old uremic male on CAPD was admitted on February 27, 1987, in a state of bacterial peritonitis. After admission, his general status deteriorated in spite of systemic and intraperioneal administration of several series of antibiotics with intermittent peritoneal dialysis. Because he developed serious sepsis, intermittent hemodialysis was started after removal of the Tenckhoff catheter. Three weeks later, CT incidentally showed a subcapsular liver mass indicative of abscess. At exploratory laparotomy on April 15, 1988, a ruptured subcapsular hematoma of the anterior aspect of the right lobe of the liver, which measured 9 by 8cm, was found. The capsule of the hematoma was debrided and hemostasis was achieved. The patient's recovery was uneventful; he was discharged on the 38 th postoperative day.

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