The periodic oral administration of high doses of 1, 25-dihydroxyvitamin D (1, 25-(OH)₂D pulse therapy) has been reported to be effective in reducing the serum levels of parathyroid hormone (PTH) in severe cases of secondary hyperparathyroidism (Nephron 51: 130-131, 1989). To clarify the mechanisms of this therapy, the effects of short-term oral 1, 25-(OH)₂D on the response of PTH to blood calcium level were evaluated in 6 hemodialysis patients with secondary hyperparathyroidism. Blood ionized calcium and serum intact PTH were measured during high calcium dialysis (Ca=5.5mEq/l) and low calcium dialysis (Ca=2.5mEq/l) before and after two 4μg doses of oral 1, 25-(OH)₂D.
The basal PTH fell from 333.5±185.2pg/ml to 181.2±95.1pg/ml after 1, 25-(OH)₂D without a change of blood ionized calcium. The linear regression line between the blood ionized calcium and the serum PTH (Y=AX+B, Y; PTH, X; free calcium) shifted downward after 1, 25-(OH)₂D. The maximum PTH induced by conditions of low calcium fell from 394.7±132.1pg/ml to 223.3±154.0pg/ml, while the minimum PTH induced by conditions of high calcium did not change significantly.
We conclude that short term oral 1, 25-(OH)₂D pulse therapy suppresses PTH secretion without changing blood calcium levels and that it changes the response of PTH to blood calcium. These results suggest that the suppressive effect of 1, 25-(OH)₂D on PTH is partly attributable to the change of sensitivity of the parathyroid gland to blood calcium.

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The decreased binding of anionic drugs to serum protein in chronic renal failure (CRF) is now well documented. We previously reported that 3-carboxy-4-methyl-5-propyl-2-furanpropanoic acid (CMPF) is a major endogenous protein binding substance and a drug-binding inhibitor retained in CRF serum. CMPF inhibits phenytoin and dyes binding to serum protein and serum albumin at the concentrations usually observed in CRF serum. Taking into consideration the hypoalbuminemia usually observed in CRF however, CMPF does not entirely account for the impaired phenytoin binding found in CRF serum. This observation suggests the presence of other drug-binding inhibitors, not yet identified, in CRF serum. In this study, we separated serum albumin from normal and CRF sera by fast protein liquid chromatography (FPLC) and ligand affinity chromatography (LAC) using phosphate buffer, pH 7.4, as an eluent, and analyzed the albumin-binding ligands by reversed-phase high performance liquid chromatography (HPLC). The HPLC peak having the highest UV absorbance was only CMPF in both samples obtained from FPLC and LAC. Weak albumin-binding substances such an indoxyl sulfate were not detected. These results indicate that the only major potent albumin-binding substance may be CMPF and that retention of other potent binding substances is scarce in CRF serum. These observations suggest that the weak binding substances retained in CRF serum contribute to a certain extent to the inhibition of protein binding observed for some drugs in CRF.

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To evaluate the significance of measureing Cu, Zn-SOD in chronic renal disease, we determined plasma superoxide dismutase (SOD) enzyme (biological) activity and Cu, Zn-SOD immunological activity, and analyzed Cu, Zn-SOD isomer using gel column chromatography.
Plasma SOD was determined as biological activity using nitrite method and immunological activity using a sandwich enzymeimmunoassay technique. Subjects consist of 185 patients with chronic glomerular diseases and 20 patients undergoing hemodialysis therapy. Controls were 170 healthy persons.
Both the biological and immunological activities of SOD were increased and showed reversed correlation with creatinine clearance in the patients with chronic glomerular diseases. In the patients under hemodialysis, we obserbed marked increases in immunological activities of plasma Cu, Zn-SOD, comparing in biological activities of plasma SOD.
By gel column chromatography, we found a marked increase of Cu, Zn-SOD monomer that was enzymatically inactive.
In regard to the increase of SOD activities according to decrease of renal function, we conclued that Cu, Zn-SOD was pooled by decrease of the excertion of this enzyme. Our results revealed that marked increase of Cu, Zn-SOD immunological activities in hemodialysis patients was caused by increase of Cu, Zn-SOD monomer.

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In order to clarify the meaning and mechanism of complement changes in patients with chronic glomerulonephritis requiring, chronic hemodialysis complement fragments C4d, iC3b & Bb, strict indicators of complement activation, were measured by ELISA using monoclonal antibody (Fuji, Rebio). C₃, C₄, and CH50 were also detected. At the same time measurement of circulating immune complexes (CIC) was carried out by ELISA (Cytotec CIC Kit: C1q method) to detect complement activating factor.
The results were as follows: complement fragments-C4d, iC3b & Bb-and CIC in chronic hemodialysis (HD) patients showed significantly higher levels than those in normal subjects. Furthermore, the levels of C4d and iC3b in HD patients with high CIC were significantly increased over those with normal CIC.
In conclusion; 1. In addition to alternative pathway, classical pathway with which CIC were involved was also activated in HD patients with glomerulonephritis. 2. No correlation between complement fragments and the duration of hemodialysis was seen.
These facts are very interesting considering the clinical symptoms and various complications of HD patients.

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Protein (albumin)-bound indoxyl sulfate is markedly increased in the serum of hemodialysis patients. Since protein-bound indoxyl sulfate cannot be removed efficiently by hemodialysis, we studied the effect of oral sorbent AST-120 on the serum concentration of indoxyl sulfate in hemodialysis patients.
The hemodialysis patients administered oral sorbent AST-120 showed a marked decrease in the prehemodialysis serum concentration of indoxyl sulfate as compared with control hemodialysis patients. The serum concentration of creatinine and urea nitrogen, however, did not decrease after the oral administration of AST-120. Administration of AST-120 to hemodialysis patients with pruritus caused an improvement in itching.
AST-120 was effective in decreasing the serum concentration of albumin-bound indoxyl sulfate in hemodialysis patients. This was due to the inhibition of indoxyl sulfate synthesis in the liver as a result of the adsorption of indole, a precursor of indoxyl sulfate, in the intestine.

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We analyzed the causes of shoulder pain in long-term hemodialysis patients by means of clinical, endoscopic and histological observations. We conclude that the shoulder pain comes from shoulder impingement syndrome. Resection of the coracoacromial ligament using the Universal Subcutaneous Endoscope system relieved the clinical symptoms. However, continuous hemodialysis will deposit amyloid originating from β₂-microglobulin in the connective tissues and may cause a recurrence of the clinical symptoms. It is expected that new types of artificial kidneys will remove β₂-microglobulin in the near future.

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In order to determine the influences of renal function and hemodialysis (HD) on the pharmacokinetics of denopamine (D), an orally inotropic agent, the pharmacokinetics of a single dose of 10mg D were studied in 5 patients on maintenance HD and 21 patients with various degrees of renal impairment. Blood samples were taken before and 1, 3, 6, 12 and 24 hours after an oral administration of D.
In patients on HD, studies were performed both on a non-HD and a HD day separated by more than 7 days.
Tmax was significantly longer in the group whose creatinine clearance was less than 20ml/min than in the group whose creatinine clearance was normal. However, Cmax, T1/2 and AUC did not show any significant difference among the groups. Also, HD did not change the pharmacokinetics of D and the dialysis clearance was 33ml/min.
These results suggest that adjustment of the dosage of D should not be necessary in patients with renal impairment, even in patients on HD.

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Continuous monitoring of the blood pressure is necessary during hemodialysis treatment to detect patients who show sudden pressure reduction.
It was formerly reported that there exists a statistically significant relationship between the fistulated venous pressure and the systemic arterial pressure.
We have developed a method of measuring the intravascular pressure near the A-V fistula by mounting a pair of pressure sensors on the both ends of an extracorporeal blood circuit.
Experimental studies during clinical treatment show the feasibility of this method which is insensitive to changes in blood pumping rate or ultra-filtration rate.

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Peritonitis is a frequent complication of continuous ambulatory peritoneal dialysis (CAPD). Intraperitoneal administration of antibiotics has been the treatment of choice in such cases. However, this procedure is cumbersome and requires hospitalization. With the advent of novel fluoroquinolones, such as ciprofloxacin (CPFX), it has become possible to treat these patients by oral administration of the drug. Between September 1 1988 and August 31 1989, we treated 5 cases of CAPD peritonitis with oral CPFX. Immediately after admission, these patients were given 800mg of CPFX. They then underwent peritoneal lavage three times. Subsequently 200mg of CPFX was given orally three times a day. The drug concentration in the plasma and the dialysate were monitored for 1 week and were kept higher than the MIC of the causative organisms which included Staphylococcus aureus, Strep. viridans, E. aerogenes, and Moraxella sp.. Infection was cleared within 8 days in all cases. However, a relapse was noted in one patient who was given aluminum-based antacids during the treatment. In this case, the concentrations of CPFX in both the plasma and the dialysate were much lower than those of other patients. We conclude that oral CPFX is effective in the treatment of CAPD peritonitis. Simultaneous administration of antacids may interfere with the effectiveness of the treatment.

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The currently used CAPD dialysate, the slight acidity of which prevents glucose degradation, may cause peritoneal membrane problems as a consequence of repeated administrations. To evaluate the effects of neutral CAPD dialysate in long-term application, a 5-month clinical study was performed with dialysate neutralized by an NaHCO₃ addition to the system.
The neutral CAPD dialysate was prepared by adding 12ml of 8.4% NaHCO₃ solution to Dianeal PD-1 (Baxter) through the injection port by use of a reconstituting device (Baxter) just before every administration. The final pH was 6.8 and the NaHCO₃ concentration was 6mmol/l The final lactate concentration was 35mmol/l and that of Na was 138mEq/l A 5-month clinical study was performed on 8 wellcontrolled CAPD patients comparing Dianeal PD-2 as pre-and post-control dialysates. The changes in blood chemistry, drainage chemistry and white blood cell counts in the drainage were measured, and subjective symptoms were recorded by means of questionnaires to patients.
Blood HCO₃^- levels significantly improved during the use of the neutral dialysate. Blood Na, Cl and Mg levels, and the drainage volume significantly increased. Negative Na-balance was increased during the administration of the neutral dialysate. Levels of blood IgG slightly decreased. The total white blood cell count in the drainage decreased. Other examined parameters changed little. As for the changes in subjective symptoms, abdominal bloating, abdominal pain at instillation time, nausea and headache were improved. No side effects, including peritonitis, occurred when the neutral dialysate was used, but there were some episodes of peritonitis in the pre-and post-control tests with use of Dianeal PD-2.
The CAPD dialysate neutralized by NaHCO₃ seems to have a less stimulatory effect on the peritoneal membrane and does not after the theraputic effects of CAPD. The neutral CAPD dialysate seems have certain advantages in the long-term treatment of CAPD patients.

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We introduce here an operative method of CAPD catheter insertion used in our hospital and report on complications which necessitated removal of the catheter. We should pay attention to certain points when surgically inserting a catheter. These points are: 1. use of the curl type (double cuff) Tenckhoff catheter. 2. insertion the curl portion of catheter into the Douglas pouch. 3. to make the minimum feasible laparotomy incision and to pursedouble suture tightly. 4. to keep a distance of 5-7cm from the 2nd cuff to the exit, and so on.
We experienced fouty-four CAPD catheter insertions in the ten years from 1981 to 1990. Fifteen catheter complications occurred in ten years, including seven poor drainages, one leakage of solution, two tunnel infections, two exit infections, one 2nd cuff erosion, and one case each of severe pain and bleeding in the peritoneal cavity. All fifteen complications necessitated removal of the catheter. After six poor drainages had ocurred with the straight type in the first seven years of the study, only one occurred while using the curl type in the last three years. Poor drainage is the main element of early complication, because most of our poor drainage problems occurred eighteen days or more after the insertion of the CAPD.
One patient experienced three episodes of serious complication in the course of four insertions (two tunnel infections and two exit infections). We expect that poor aseptic technique and an immunity disorder were partially responsible.
Most complications are prevented by attention to detail and careful technique during the surgical insertion. It is important that we constantly strive to improve the operative method.

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Since April 1987, we have visited a number of emergency hospitals in the neighborhood in our capacities as transplant coordinators with the purpose of obtaining many more cadaveric donations for kidney transplantation. The numbers of visits made for this purpose were 185 to 3 emergency medical facilities, 52 to 2 municipal hospitals, and 126 to 8 private hospitals, during the 29 months from April 1987 to August 1989. Our goal was to educate as much of the medical staff of the emergency hospital as possible to understand the present state of cadaveric kidney transplantation in Japan, and requested that they inform us of potential donors with brain death. The practical result from a total of 363 visits over the 29 months, was that we were informed of 31 potential donors, and 25 donations for kidney transplantation were actually made. And 27 of the 31 of which we were informed and 23 of the 25 donors were from 3 emergency medical facilities. As a result of our work as transplant coordinators for more than two years, it seems to us that the staffs of municipal and private hospitals should be more positively enlightened about the cooperative aspects of donations for kidney transplantation.

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For the 8-year period from April 1981 to March 1989, 49 hemodialysis patients underwent surgery at our hospital for a variety of reasons other than for hemodialysis, and laparotomy was performed in 33 of these patients. The authors reviewed these cases of abdominal surgery to determine the incidence of postoperative complications and mortality.
The incidence of postoperative complications among the patients who underwent abdominal surgery at our department was 39% (13 of 33). There was no significant difference between those patients who had had emergency operations and those who had had palliative surgery, but postoperative complications occurred more frequently in those patients who had had major surgery. Death occurred in 5 of 13 patients with postoperative complications-a high rate of 38%. Major surgery, or the extent of surgical invasion, could be roughly classified into three groups, each of which showed different patterns of postoperative blood BUN concentration, and different incidences of postoperative complications. The onset of postoperative complications in the dialysis patients strongly suggested the influence of chronic renal failure on pathology such as delayed wound healing, decreased immunological function and the presence of coagulation disorders. These findings indicate that the result of surgery is strongly influenced by the quality of the pre- and postoperative management of uremia.

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During the period from 1978 to 1989, 499 patients suffering from chronic renal failure (CRF) were treated by hemodialysis (HD) in the Nagasaki Municipal Medical Center. Among these cases, 54 patients (10.8%) were diagnosed as having an acute exacerbation of CRF and were studied for this report. They were 27 males and 27 females and their mean age was 66 years.
Acute exacerbation was diagnosed by the following three criteria: 1. ongoing renal disease; 2. preexisting renal insufficiency (creatinine levels: 2.0-7.0mg/dl); 3. initiation of dialysis therapy within two months from the onset of exacerbation.
The ongoing renal disease were nephrosclerosis in 19, diabetes in 18, chronic glomerulonephritis in 7, amyloidosis in 4 and in the other 6 cases. The main causes of acute exacerbation were heart failure, dehydration, infection and anasarca.
After exacerbation, the mean creatinine level increased from 3.6mg/dl to 7.5mg/dl, but there were only 16 patients with creatinine levels higher than 8.0mg/dl, In the other cases, symptoms requiring the initiation of HD were heart failure, oliguria, electrolyte imbalance, anasarca, etc. The prognoses were maintenance of HD in 7, discontinuance of HD 12, and death in 35 (after discontinuance of HD in 10).
The patients in whom HD was discontinued were characterized by the following points: 1. younger mean age; 2. shorter duration between onset of acute exacerbation and initiation of HD; 3. decreased urine volume, lower BUN levels and a slight degree of anemia at the initiation of HD; 4. lower number of failing organs. The creatinine level, however, was not a significant prognostic indicator.

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Hypercalcemia is one of the life-threatening complications of malignant neoplasms. We, therefore, investigated the effects of Ca-free HD on hypercalcemia associated with malignant neoplasms. Seven patients with hypercalcemia associated with malignant neoplasms (4 adult T-cell leukemia, 1 parathyroid tumor, 1 uterus cancer, 1 multiple myeloma) were treated with Ca-free HD in order to improve their critical hypercalcemia. The levels of serum creatinine and blood urea nitrogen before HD were 2.6±1.4mg/dl and 63±27mg/dl respectively. The contents of the Ca-free dialysate which was used in this study were 135mEq/l of Na⁺, 2.5mEq/l of K⁺, 103mEq/l of CI^-, 8mEq/l of CH₃ COO^-, and 30mEq/l of HCO₃^-. Ca-free HD significantly reduced the serum Ca (Ca²⁺) concentrations of the patients from 15.1±2.5mg/dl (4.61±1.09mEq/l) to 11.4±1.4mg/dl (3.01±0.24mEq/l). Clinical symptoms such as unconsciousness were markedly improved. The serum Ca concentration at one hour after the start of Ca-free HD had decreased to 82.3% of the pre-HD value. The reduction rate of serum Ca (Ca²⁺) concentration was highest during the first hour of Ca-free HD. There was a significant correlation between initial serum Ca concentrations and the amounts of reduction of serum Ca concentration caused by Ca-free HD. Twenty-four hours after Ca-free HD, serum Ca concentrations again increased to almost the same values as before the treatment. These results indicate that Ca-free HD could markedly and rapidly improve critical hypercalcemia despite its effect being transient. As it takes at least half a day to improve critical hypercalcemia with drugs such as mithramycine, Ca-free HD should be utilized as an emergent treatment for patients with life-threatened hypercalcemia.

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Three hemodialysis (HD) patients who had frequent dialysis-induced hypotension underwent a continuous infusion of Glyceol^® (100ml/hr) combined with intermittent infusions of 10% NaCl (20ml) at the start of HD and at 1, 2 and 3 hrs after the start of HD, to prevent dialysis-induced hypotension.
The frequency of dialysis-induced hypotension was significantly decreased in all patients and the predetermined ultrafiltration volume for each patient could be gained. Subsequently, decreases of body weight and of cardiothoracic ratio were recognized after HD in all patients. However, increases of interdialytic body weight and blood pressure before HD probably due to a rise of water intake resulting from thirst, were noted.
It is concluded that a continuous infusion of Glyceol^® combined with intermittent infusions of 10% NaCl can be effective in preventing dialysis-induced hypotension. However, further studies are required to determine the appropriate doses.

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Pruritus is a frequent and troublesome complication in hemodialysis patients. Among the various mechanisms reported, dry skin is considered to be a possible cause of uremic pruritus.
We evaluated the efficacy of a bath preparation of mixed garlic extracts and vitamin B₁ complex on uremic pruritus. In addition, the changes of the skin water content were examined before and after the bath preparation treatment by measuring the conductivity of the skin with an in vivo water sorption-desorption test. Relief from itching was obtained in 6 out of 8 patients (75%) treated with the bath preparation for 6 weeks. The hydration state, hygroscopicity and water holding capacity of the skin, which indicate the degree of the skin dryness, were improved in all cases.
The application of a bath preparation mixed of garlic extracts and vitamin B₁ complex was concluded to be effective in uremic pruritus.

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We had three elderly patients on hemodialysis therapy from 1988 to 1989 who experienced falls.
We therefore examined the reasons for falls in elderly patients. We conducted a survey which focused on “walking” in 172 outpatients who were on hemodialysis therapy. The age range of the respondents was from 13 to 78 years. We also conducted “sit down upon the heels and stand up tests” and “stand on one leg tests” in order to assess brown of the legs, ROM, and balance. We discuss the results related to age, hemodialysis history, and diagnosis, and conclude the factors related to falls.
With regard to the survey, 47.6% respondents answered that they experienced falls or near falls after being on hemodialysis therapy. In the group over 60 years of age, more than 45% had had falls. The most common place for falls was in the road. The second most common place was uneven surfaces such as ladders and threshholds. The third most common place was inside the house. Falls were markedly common when their care giver was not present.
The most common reason for walking dysfunction was moving disability of the legs. This was very evident for patients who had received hemodialysis therapy for a long time. The results of the “stand on one leg test” were lower than the Japanese average. In the group over 60 years of age, only 17% could stand still for more than 5 seconds. Diabetes patients'results were generally worse.
We found the 3 factors influencing falls among elderly patients who were on hemodialysis therapy were: 1. Envioronmental factors the absence of a care giver, on the road, uneven surfaces, and inside the house. 2. Patient factors-moving disability and dysfunction of senses owing to age, poor eye-sight and poor balance because of diabetes. 3. Hemodialysis therapy factors-visiting the hospital 3 times a week, disturbance of balance, limitation of ROM and stiffness of the body because of long term hemodialysis therapy.

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Although extrapulmonary tuberculosis (TB) is more common in patients on maintanance hemodialysis than in the general population, reports of tuberculous spondylitis are rare. We experienced a patient with tuberculous spondylitis who was successfully treated by surgical therapy.
A 39-year-old female on maintenance hemodialysis for five years was admitted to our hospital because of fever and right back pain of four months'duration. Chest X-ray tomography. CT and MRI disclosed a low density tumor and destruction of the spinal hones at T5-T6, associated with positive tuberculin test, fever, increased ESR and strongly positive CRP. Conventional anti-TB therapy with isoniacid (300mg/day), rifampicin (450mg/day) and streptomicin (0.5g twice a week) failed to improve the symptoms of tuberuculous spondilytis. Surgery was performed on the 34th hospital day. After that, fever, right back pain. ESR and CRP improved rapidly. She was discharged after 3 months of rehabilitation and returned to chronic ambulatory hemodialysis.
Tuberculous spondylitis must be considered as a possible cause of unknown fever in patients on chronic hemodialysis, hecause any delay in initiating therapy might result in a serious outcome.

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We report on a case of hypoglycemic coma during HD. A 68-year-old male with a 1.4 year history of maintenace HD reguired for hypertensive nephrosclerosis developed a hypoglycemic coma during HD using bicarbonateglucose free dialysate. Further examinations suggested that malnutrition and its associated conditions such as a low intake of glucose, poor glycogenesis due to decreased hepatic glycogen storage, and poor glyconeogenesis due to decreased alanin may have been responsible for the dialysis-induced hypoglycemia. Our case suggests that those patients with poor nutrition should avoid fasting during HD.

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A sixtyfour-year-old woman on maintenance hemodialysis diveloped bilateral facial palsies which recovered after HDF (hemodiafiltration). Eight months later, she began to show a disturbance of recentmemory and an inability to concentrate. She underwent HDF again and these neurological symptoms were ameliorated. Several determinations of serum aluminium were done but it was not increased appreciably, however the titer of IgG antibody against Borrelia burgdorferi was increased as much as 800-fold over that of the control using the immunoperoxidase method. The titers were decreased by HDF and the clinical symptoms of encephalopathy were also correlated with these titers. Taken together, this encephalopathy was probably due to a late complication of Lyme disease (stage 3).

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We report on a case of idiopathic thrombocytopenic purpura (ITP). This patient showed a remarkable generalised bleeding tendency which was refractory to various therapies. Therapeutic plasmapheresis (TPP) was given to increase the platelet count and then splenectomy was performed, and the platelet count became normal.
The patient was a 23-year-old male presenting with gingival bleeding and general purpura without any predisposing causes. The platelet count was as low as 0.1×10⁴/mm³ and remained unchanged despite the transfusion of 60 packs (20 packs/day×3 days) of platelet concentrate and the administration of hydrocortisone 500mg, prednisolone 60mg and methylprednisolone 1g. He was therefore admitted to the hospital.
On admission, the patient exhibited a remarkable bleeding tendency with slight nasal bleeding, gingival bleeding, hematuria, tarry stools and generalized diffuse petechiae and purpura. Antiplatelet antibody was negative, and platelet-associated immunoglobulin G (PA-IgG) was as high as 390.1ng/10⁷ cells. Bone marrow aspiration showed an increase in megakaryocytes, leading to the diagnosis of ITP.
High-dose methylprednisolone therapy (starting at 1, 000mg/day followed by a gradual reduction) and highdose γ-globulin therapy (dried pH 4-treated human immunoglobulin 2.5g×20 vials, i. v.) improved the platelet count only to 1.2×10⁴/mm³, and the bleeding tendency persisted. Endoxan 1, 000mg/day was then administered, but this produced no improvement in symptoms. TPP therapy was therefore undertaken. Since this tended to elevate the platelet count, TPP was performed for a total of six times. During the therapy, the platelet count increased to a peak of 10.4×10⁴/mm³ but tended to decrease again. Splenectomy was performed when the platelet count was 6.1×10⁴/mm³. The platelet count increased remarkably to 67.2×10⁴/mm³ and remained normal thereafter so the patient was discharged.

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The patient was a 43 year old female who had been diagnosed as having rheumatoid arthritis (RA) 17 years before, had an 8 year history of congestive heart failure and had suffered from chronic renal failure for 2 years.
Four months prior to admission to our hospital, hemodialysis therapy for chronic renal failure was initiated at another hospital. She was admitted in our facilities for control of nausea, anorexia and congestive heart failure.
The cardiothoracic ratio was 58.8%, ECG showed a QS pattern in leads V₁, V₂ and UCG disclosed a granular sparkling appearance of the interventricular septum. Gastro-duodenal, rectal and cardiac biopsy contained amyloid deposition that stained positively with Congo-red, was birefringent and was sensitive to KMnO₄ treatment. Moreover, immunohistochemical staining (PAP method) revealed β₂-microglobulin (β₂-MG) and amyloid A (AA) protein antigenicity in the same area of amyloid deposition.
After the application of a cellulose triacetate membrane from cuprophan to decrease the serum AA protein and β₂-MG and ingestion of 20% DMSO solution to dissociate the deposited amyloid, the patient's general condition was markedly improved. However, these therapies for inducing regression of amyloidosis are obscure.

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A case of toxic epidermal necrolysis (TEN) and bleeding colitis is presented.
A 74 year-old woman was admitted to our hospital because of dyspnea and complete anuria. Since marked hydronephrosis with bilateral ureteral obstruction due to cervical cancer of the uterus was found, percutaneous nephrostomy (PNS) was performed after the initial hemodialysis therapy. In addition, whole pelvis irradiation (Co⁶⁰1.8 Gy × 18) for the cervical cancer was started. To treat the bacterial infection (Pseudomonas aeruginosa was detected at the site of the PNS and in the urine), CSF and SBPC (1.0g and 5g × 6 days, respectively) were administrated parenterally, resulting in TEN just above the irradiation area. Even though these drugs were discontinued promptly, the patient started having copious bloody stools three days later, and she died of septic shock on the sixteenth day. Autopsy findings showed bleeding colitis with deep ulceration involving the whole colon.
We believe that the co-existence of bleeding colitis and TEN suggests that these two entities have similar immunological backgrounds, and that in an immuno-suppressed state, such as with uremia or after radiation therapy, bleeding colitis may take a life-threatening course.

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A 70-year-old woman suffered from high fever, right flank pain and anorexia. She had been undergoing chronic hemodialysis for the past seven years for renal failure due to chronic pyelonephritis. She also had hypotonic neurogenic bladder dysfunction with 80ml of residual urine. Antibiotics were given intravenously, but had no effect. Echogram, CT scan, and renal arteriography revealed multiple renal cysts (ACDK), and one was diagnosed as being purulent. The case was successfully treated by percutaneous puncture and drainage. An infected cyst is an unusual complication in ACDK.

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We have successfully treated a patient with a massive right-sided hydrothorax by instillation of fibrin glue and antiplasmin into the thoracic cavity.
A 29-year-old man had entered the CAPD program in April 1990. Following the induction of CAPD, he developed chest pain, cough and dyspnea for two months. A chest x-ray film showed a right-sided massive hydrothorax. Radionuclide studies (^99m Tc-sulphurcolloid) proved a pleuro-peritoneal communication. Interruption of CAPD for 7 days did not prevent re-accumulation of the pleural effusion when the CAPD was restarted. After complate evacuation of the pleural effusion, fibrin glue was infused into the thoracic cavity. He developed only mild chest pain and a slight fever after administration of the drug. Twenty-one days later, CAPD was restarted again and a recurrence of the pleural effusion was noted. After the addition of antiplasmin however, the pleural effusion did not reaccumulate.
As for pleurodesis after failure in treating hydrothorax by temporary interruption of CAPD, talc, tetracycline, and autologous blood have been tried. However, these substances are not completely effective and are associated with moderate or severe discomfort.
In our experience, fibrin glue and antiplasmin eradicated the pleuro-peritoneal communication without any untoward effect.

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We report 2 patients with chronic heart and renal failure, resulting from amyloidosis secondary to rheumatoid arthritis (RA), which was well controlled with CAPD.
Case 1 was a 75-year-old woman diagnosed as having RA in 1981. Proteinuria appeared in 1983. Renal function deteriorated in 1987, and became worse in July, 1989. As severe heart failure contraindicating HD was present, CAPD was instituted in Aug. Uremia, edema and the symptoms of heart failure were controlled well. In March, 1990, amyloid deposition was detected by gastric biopsy, around which time the heart failure again became worse and the blood pressure fell. Bradycardia was noted on May 1, and the patient died on May 7. Autopsy revealed marked accumulation of AA-type amyloid in the heart, kidney, thyroid, pancreas, alimentary tract and medium and small arteries all over the body.
Case 2 was a 72-year-old woman diagnosed as having RA in 1982, Proteinuria and renal dysfunction appeared in 1988. In Sep., 1989, AA-type amyloid deposition was detected in biopsies of the small salivary glands and thyroid. Renal function was slightly improved by dimethylsulfoxide (DMSO), but it rapidly deteriorated after the end of Feb., 1990, when the patient rejected DMSO. As severe heart failure contraindicated HD, CAPD was instituted in March. Uremia and heart failure were controlled well. Heart failure again intensified in July, blood pressure fell in Aug., and the patient died on Sep. 12.
Though severe heart failure was present, uremia was well controlled by CAPD in both cases. However, both patients died of aggravated heart failure at 8 months and 6 months respectively after the initiation of CAPD. The chief cause of heart failure seemed to be advanced amyloidosis of the heart. This suggests that the treatment to halt the advance of heart amyloidosis must be continued after the initiation of CAPD.

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