Plasma exchange has been employed in many fields. We reviewed its effect in 5 cases of refractory hyperbilirubinemia after acute liver dysfunction excluding fulminant hepatitis. Three liters of plasma replacement per session of plasma exchange was sufficient to remove bilirubin from the plasma effectively, but plasma exchange over a period of 3 consecutive days was needed to remove bilirubin from the whole body. In cases of a serum total bilirubin concentration of above 30mg/dl, the effect was less and far more plasma exchange was required. Posttransfusional hepatitis occurred in a few cases. Although plasma exchange certainly represents the most effective method for reducing the bilirubin levels, further studies on the effects of plasmaperfusion are needed since with this procedure post-transfusional hepatitis never occurs.

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This study was performed to investigate the therapeutic effects of hemodialysis (HD) on patients having multiple myeloma (MM) with renal failure. The subjects were 10 patients with MM undergoing HD. The ages ranged from 58 to 70 years old, and there were 7 males and 3 females. Two cases were IgG type, one IgA type, one IgD type, five Bence Jones protein (BJP) type, and one was non-secretary type. These cases were divided into three groups. Group A included patients dying within 1 month after initiation of HD therapy (n=6), group B consisted of patients dying within 1 year of maintenance HD (n=2), and group C of patients with long-term survival (over 5 years) (n=2).
In group A, renal failure resulted from BJP, amyloidosis, and hypercalcemia. The causes of death were infection, heart failure, arrhythmia, and DIC. In group B, one patient died from hepatic failure, 8 months after HD treatment, and another patient, though compensated for cessation of HD, died from arrhythmia 11 months later. In group C, a patient affected with non-secretary type MM has received HD for 6 years. Another patient was started on HD because of hyperviscosity, and HD and plasma exchange provided substantial recovery of renal function.
We conclude that it is not easy to estimate prognosis at the time of HD introduction. It is important to prevent lethal complications, and to initiate intensive chemotherapy and early HD therapy, in order to improve the prognoses of MM patients suffering from renal failure.

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It is well known that the serum Magnesium (Mg) level influences the parathyroid hormone (PTH) level: a low Mg level increases and a high Mg level decreases PTH. However, this relationship between Mg and PTH is controversial in uremic patients receiving hemodialysis. We studied the influence of hypermagnesemia on serum PTH levels in patients who were treated by hemodialysis.
We administered phosphate binders to 55 patients [28 males and 27 females, mean age 41.8±9.6 (SD)] for 48 months. The phosphate binders contained Mg (OH)₂ and AI₂O₃. The daily dose of Mg was 300-500mg/day. We measured serum Ca, Mg and P once per month for 48 months. Serum c-terminal PTH (C-PTH) was measured every 6 months by radioimmunoassy.
The administration of phosphate binders increased serum Mg levels from 2.55±0.04mEq/l (mean±SEM) to 2.98±0.05mEq/l after 6 months; and these elevated Mg levels were maintained up to the end of the study. In 41 patients (74%), serum PTH levels significantly decreased within 12 months of Mg repletion from 2.50±0.34ng/ml to 1.47±1.20ng/ml (p<0.01: Responders). But this effect was transient. After 18 months, its levels increased again despite the elevated Mg levels. In the other patients, serum PTH levels did not decrease in spite of Mg repletion (Non-responders).
In both groups, however serum phosphorus levels decreased after the administration of phosphate binders, while serum Ca levels did not change significantly.
We have demonstrated that hypermagnesemia induced by phosphate binders decreases serum PTH levels; but the effect does not last more than 18 months.

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1α-Hydroxyvitamin D₃ (1α-OH-D₃) supplement therapy, calcitonin (CT) therapy usually with 1α-OH-D₃ supplementation, and parathyroidectomy (PTX) are widely used treatments for renal osteodystrophy in patients on hemodialysis (HD). To assess retrospectively the effects of these treatments on renal osteodystrophy, the bone mineral density (BMD) of HD patients was analyzed. BMD was measured once for 50 HD patients at the first to the fourth lumbar vertebra (L_1-4) and at the head and neck of the femur (F_HN) by dual-energy X-ray absorptiometry (DEXA: Hologic QDR 1000).
To exclude any effects of osteoporosis on the BMD, male out-patients aged 30-55 years without diabetes mellitus, liver cirrhosis, hyperthyroidism and gastrectomy, were selected. The patients were divided into five groups depending on the kind of treatment and the serum C-PTH level: group 1 was CT (-) and with C-PTH<10ng/ml; group 2 was CT (-), with C-PTH≥10ng/ml; group 3 was CT (+), with C-PTH<10ng/ml; group 4 was CT (+), with C-PTH≥10ng/ml; and group 5 was the PTX group. The clinical results and BMD of the groups were compared.
The 1α-OH-D₃ dose per year was correlated with F_HN BMD (r=0.431, p<0.05) but not with L_1-4 BMD in group 1. The L_1-4 BMD of group 4 was higher than that of groups 1 and 2 (p<0.01), but F_HN BMD was not. Both the L_1-4 BMD and the F_HN BMD of group 5 were higher than those of group 2 (p<0.01).
Thus, the effects on L_1-4 BMD and F_HN BMD were different depending on the treatment. 1α-OH-D₃ therapy seemed to be more effective at F_HN; CT therapy seemed to have good effects on L_1-4; and PTX therapy seemed to have good effects at both locations.

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We studied the influence of rEPO on erythrocyte function in patients (26 cases) on maintenance hemodialysis.
We recognized that anemia was ameliorated by iron supplementation in anemic patients whose anemia had been improved and stabilized by the administration of rEPO. It is assumed that the administration of rEPO may stimulate production of microcytic and hypochromic erythrocytes in the condition of iron deficiency. In terms of ferrokinetics, %rcu was increased and PIDT1/2 was shortened by administration of rEPO, therefore, the utilzation of iron was increased by administration of rEPO. The life span of the erythrocyte was not significantly changed by the administration of rEPO. But there was a significant negative corrlation between the improvement in anemia and the life span of erythrocytes, ie in proportion to the improvement in anemia the life span of erythrocytes becomes shorter. The fragility of erythrocytes did not change significantly with administration of rEPO. rEPO is the most effective agent for treatment of anemia in hemodialysis patients. It is, however, postulated that rEPO stimulates the production of abnormal erythrocytes, ie microcytic, hypochromic or immature erythrocytes, in a condition of iron deficiency.

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To clarify the factors related to the loss or gain of bone mass in patients undergoing chronic hemodialysis (HD patients), we measured the ∑GS/D of 64 HD patients (47 males, 17 females). The pre and post values in each patient were measured for 24 months using the microdensitometry method. According to the changes in ∑GS/D, the patients were divided into 2 groups-an increased group and an unchanged or decreased group. Correlations between these 2 groups and clinical factors were investigated by quantification theory II. Thus, the items related to the increase of ∑GS/D are: osteocalcin-pre (≤30.0ng/ml), serum P-pre (4.5-6.0mg/dl), total dose of P-binders administered for 27 months just before the observation period (≥405.1g), serum Al-pre (≥10.1μg/l), C-PTH-post (≤3.0ng/ml), serum Ca-pre (≤5.0mEq/l), C-PTH-pre (≥3.1ng/ml), total dose of Vit. D₃ administered during the observation period (≥180.1μg). These results suggest that an adequate dose of P-binders and Vit. D₃ may prevent the deterioration of ROD.

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Recently, with the frequent use of high-flux membranes, bacterial contamination and endotoxin pollution of the dialysate have become an important issue in hemodialysis (HD), and the hazards of subunits or small fragments of endotoxins passing through the membrane by back diffusion or back filtration from the dialysate into the blood of HD patients have been increasingly discussed. In this study, antibodies against endotoxins in the blood of HD patients were measured by means of the ELISA method, which is more sensitive and specific to endotoxins than conventional methods.
Initially, the bacteria in the dialysate were collected and identified. Endotoxins were subsequently extracted by Westphal's phenol method. Furthermore, cross reactivity between endotoxins from the dialysate bacteria and E. coli J-5 was confirmed by the ELISA method. The titers of the standard anti-endotoxin antibodies obtained from a rabbit immunized by heat-killed bacteria were measured by immunoblotting, and the criterion for antibody positivity was decided on the basis of this result. After these preliminary experiments, the antibodies were measured with E. coli J-5 endotoxins as antigens in 101 HD patiens and 21 normal volunteers by means of the ELISA method. As a result, 19% of the healthy controls and 26% of the HD patients using conventional membranes were antibody positive, while 60% of the patients using high-flux membranes were antibody positive. This value was significantly higher than those of the other two groups. These results strongly suggest that endotoxins in the dialysate may pass through membranes, especially high-flux membranes.

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It has been shown statistically that dialysis patients have a higher incidence of at least some malignancies than the general population. Tumor markers (TM) are useful in general, but sometimes decisions are difficult, because definite criteria are not yet available for hemodialysis (HD) patients. The purpose of this paper is to identify appropriate TM cut-off levels in HD patients.
Serum levels of 14 TMs were measured in 173 HD patients free of both malignancies and non-malignant conditions which might positively affect the results.
A comparison was made with the results in 100-130 controls, and TM cut-off levels in HD patients were determined tentatively by means of parametric analyses as follows (values in parentheses represent the controls): EL-1 131-707ng/ml (100-400), CA-50 71 U/ml (35), CA19-9 76 U/ml (37), BFP 166ng/ml (75), SLX 45 U/ml (30), CEA 6.9ng/ml (2.5), IAP 1, 068μg/ml (500), SCC 6.5ng/ml (1.5), TPA 447 U/l (110). The cut-off levels of 5 TMs (AFP, CA-125, PAP, PA and ST-439) in the HD group were the same as in the control group. Serum levels of 14 TMs were compared in the group on HD for less than 2 years and the group on HD for over 10 years; only two TMs (PAP and TPA) were statistically significantly higher in the latter group. A difference between males and females was found only in the case of CA19-9 (females>males). There was no significant correlation between TMs and BUN or serum creatinine. The reason for the elevation of certain TMs in HD patients is unclear, but the production, release, degradation, excretion, etc., of TMs in HD patients may be involved in this phenomenon. It is concluded that certain tumor markers require modified cut-off levels in chronic HD cases in which TMs are able to maintain their clinical value.

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We compared the frequency of abnormal UF error between two different periods, by performing 1, 000 cansecutive hemodialysis (HD) for each using the same four consoles. In phase 1, the consoles were checked monthly by BT after HD and in phase 2, BT was done daily before HD. The frequency of abnormal UF error, i.e. more than 250g, significantly decreased from 97 HD in phase 1 to 44 HD in phase 2 (p<0.001). Factors influencing abnormal UF errors included machinary trouble, reduced from 7 in phase 1 to 3 in phase 2 and unknown factors, reduced from 87 in phase 1 to 40 in phase 2. In phase 1, all 7 repairs of the consoles due to machinary trouble were done after HD. In phase 2, however, 10 repairs due to the detection of machinary trouble by BT were done before HD, and only 3 repairs were performed after HD.
We conclude that daily checking of consoles with UFC by BT is a useful method of decreasing the frequency of abnormal UF error during HD.

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Hemodialysis access shunts which became unnecessary because of well-functioning grafts following renal transplantation give rise to a variety of problems.
We have carried out internal shunt closure (resection of the anastomosis site) in 11 renal graft recipients (9 males; 2 females) complaining of pain and circulatory disorders as a result of thromboangiitis. Nine of the 11 patients also underwent end-to-end anastomosis of the radial artery (angioplasty); a homograft (Biograft) was replaced in 1 case because of the length of the portion of the radial artery resected. The remaining 2 cases underwent only shunt closure because of technical failure. The postoperative followup period has been 5 to 53 months (average: 17 months). Ali patients continue to have well-functioning grafts and good revascularization has been observed at every site of anastomosis.
Although we have only performed shunt closure in selected cases in which there were troublesome complaints, we now recommend shunt closure and angioplasty in all patients who continue to have excellent graft function over a long period of time, because the procedures are effective and relatively non-invasive.

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Questionnaires were sent to 2, 030 dialysis units in February 1990, to determine the present status of renal cell carcinoma in chronic hemodialysis patients. The response rate of 64% covered about 65% of the 88, 534 dialysis patients in Japan. Renal cell carcinomas were detected in 130 dialysis patients between February 1988 and February 1990. The age of the 130 patients (112 males and 18 females) was 52.6±10.9 years (mean±SD), and the mean duration of dialysis was 106.0±82.3 months. The clinical diagoses were based on CT (59 cases) and sonographic examination (48 cases). There were only 15 symptomatic patients. The original kidney disease was chronic glomerulonephritis in 108 cases. Acquired renal cystic disease was found in 102 out of 124 renal cell carcinoma patients (82.3%). Curative nephrectomy was performed in 99 out of 129 patients. The mean tumor diameter was 4.2±2.5cm, (range: 0.5-15.0). Bilateral renal cell carcinomas were found in 11 of the 130 patients. Moreover, 19 out of 126 patients had metastases. The four previous questionnaires (1982, 84, 86 and 88), as well as the present one revealed a total of 364 renal cell carcinomas. Among these patients, the 276 with acquired renal cystic disease were younger and had a longer duration of dialysis and lower metastatic rate (13.6%) than the 76 patients with no or few acquired cysts (metastatic rate 27.4%). In conclusion, the incidence of renal cell carcinoma in dialysis patients was 41 times higher than in the general population. Metastasis was observed in 15.1% of this series.

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We investigated retrospectively the clinical features and factors influensing the prognosis in 22 patients with SLE (2 females, 20 males) who were undergoing a hemodialysis treatment in the 2nd department of internal medicine, Nagasaki University and affiliated hospitals from, 1978 to 1989.
These cases were divided into 3 groups as follow, A) maintenance hemodialysis (n=14), B) death within 2 months after start of hemodialysis (n=5), C) substantial recovery of renal function by hemodialysis (n=3). The following data were evaluated for these 3 groups: clinical data, periods of treatment before hemodialysis, dosages of steroid, activities of SLE, and renal biopsy findings.
The renal biopsies of 17 cases revealed 1 of category II, 2 of category III, 8 of category IV and 6 of category V, of the WHO classification. There was no significant differences in the activity index between the 3 groups, but the chronicity index of group A was higher than that of other groups. In group A, the period of treatment before hemodialysis was long (105 months on average), and the renal function had decreased gradually. The SLE activity was not high, and the steroid dose was a maintenance dose at the start of hemodialysis. It was possible to decrease the dose of steroid or to cease its administration. In group B, the prior period of treatment was short and renal function had decreased rapidly. The SLE activity was high, and the steroid dose was high at the start of hemodialysis. The etiologies of death were infections, DIC and CNS lupus. In group C, the hemodialysis was started at the time of infection, but the SLE activity was not high. The renal function recovered after 14 months in 1 of them, and after 2 weeks in 2 of them, but 2 of them needed hemodialysis again.

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Recombinant human erythropoietin (rEPO) is the preferred treatment for anemia in chronic hemodialysis patients. The general status of hemodialysis patients improves, increasing their hematocrit value. Some patients have regained their erectile function after the use of rEPO. We examined the erectile function of hemodialysis patients before and after treatment for anemia with rEPO and performed a pharmacological study of rEPO on isolated human corpus cavernosum tissue.
An improvement of erectile function was seen in four of 9 hemodialysis patients who were treated with rEPO. rEPO produced no pharmacological effects on isolated human corpus cavernousum tissue.

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A multicenter cooperative study was designed to evaluate the efficacy and safety of FR-860 as an anticoagulant in hemodialysis. Sixty-five stable maintenance hemodialysis patients were enrolled into the study from fourteen institutions in Japan. 4 cases were excluded from the efficacy analysis because of protocol deviation (a violation of the concomitant drugs). The period of the study was fixed at two weeks. Dosage requirements were 15.0-20.0 anti-Xa units/kg as a bolus and 7.5-10.0 anti-Xa units/kg/hr for continuous hourly administration. Total dosage of FR-860 (F) was 2, 505±127 anti-Xa units compared to that of a conventional heparin (CH) dose of 6, 124 ±190 units. No difference in the residual blood in the extracorporeal circuit was observed between the F and CH groups. The hemostatic time at the puncture site after the completion of dialysis was significantly shortened in the F group (7.9±0.7 min) in comparison with the CH group (11.4±1.1 min; p<0.01). The plasma anti-Xa levels were 0.24±0.03 and 0.36±0.04 units/ml 1 hr after the initiation and at the completion of dialysis, respectively. ACT, measured by the Hemochron method, was not prolonged during dialysis. APTT varied from 34.3±1.2 before dialysis to 41.0±1.9 (p<0.01) 1 hr after the start of dialysis and 39.9±1.6 sec (p<0.01) at the end of dialysis. Plasma AT III activity increased from 96.8±2.5 before dialysis to 113.0±3.2% (p<0.01) at the end of dialysis. No significant changes were observed in either ADP-or collagen-induced platelet aggregation during dialysis. Dialysis efficiency in the F group was similar to that in the CH group. Slight itching developed in one of the 65 cases. No abnormal laboratory data were observed during the study.
In conclusion, FR-860 was demonstrated to be a convenient alternative to conventional heparin as an anticoagulant in hemodialysis treatment.

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The efficacy, safety and pharmacokinetics of carvedilol were investigated in six patients with chronic renal failure associated with hypertension who were undergoing hemodialysis.
The plasma levels of unchanged carvedilol after single 10mg doses, whether taken during hemodialysis or on the following day, reached a peak, in both cases, 1-5 hours after administration. The drug was gradually metabolized thereafter and had almost disappeared after 24 hours. Blood pressure gradually decreased due to administration of carvedilol on either day, that is with and without hemodialysis. There was little removal of carvedilol from the body due to hemodialysis, and hemodialysis had almost no effect on the blood levels of carvedilol.
When carvedilol was administered continuously for 4 weeks at a dose of 10mg once a day, the plasma levels of unchanged carvedilol did not tend to increase before early morning administration, and no accumulation was seen. The blood pressure was well controlled during the administration period and no drug tolerance appeared. No significant changes were seen in the pulse rate at any time. No side effects or abnormal laboratory test values were observed.
These results indicate that carvedilol is a safe and effective antihypertensive agent for control of blood pressure in patients on chronic hemodialysis.

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A computerized integrated dialysis chart display system was developed.
Blood pressure and pulse rate were recorded graphically with marks; body weight and time were designated by letters; all chart values obtained during dialysis were subsequently translated into digital data by using the optical character reader (OCR) and the data was put into the main computer. Laboratory data, recorded on a floppy disk at our laboratory, were transferred to the main computer by using the floppy disk reader. Other data were entered into the system by using the keyboard.
All data were integrated by newly developed graphic drawing soft ware and displayed on the monitor screen, and/or printed by the page printer, as an integrated dialysis chart.
This system, working in conjunction with the “Dialysis patient-doctor support system” developed by Toshiba Information Equipment Co. Ltd., can process the laboratory data base, the Problem Oriented System (POS) and the print control system.
We conclude that the computerized integrated dialysis chart display system, which can make an integrated chart without any awkward handwork, is a useful tool for efficient and effective management of a large number of dialysis patients.

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To assess dietary control in hemodialysis patients. Anthropometric measurements, and measurements of basal energy metabolism, energy expenditure during dialysis hours, daily caloric intake and consumption were carried out.
The results showed: 1. that hemodialysis patients were wasting and in a state of malnutrition; 2. that although female patients had almost the same basal metabolic rate as the control group, the basal metabolic rate of the male patients was rather low; 3. that the 4-hour energy expenditure of hemodialysis patients was not significantly different from that of the control group, and 4. that the daily caloric intake and consumption values were lower than those of the control group. The vital activity index was moderate in male hemodialysis patients and mild in female patients.

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In order to achieve psychosocial adjustment, end-stage renal disease (ESRD) patients require not only adequate medical services but social services as well. As a means of evaluating the psychosocial adjustment of ESDR patients, they were asked to reply to questionnaires concerning their sociodemographic background, employment status and feelings regarding social insurance and services.
In February, 1989, 273 ESRD patients at the Kidney Center of Nagoya Daini Red Cross Hospital under 60 years of age were asked to fill out questionaires. Replies were obtained from 184 patients (67.3%). Of these 184 patients, 52 patients were treated by regular hospital hemodialysis, 19 patients by CAPD, and 113 patients had functioning kidney transplants.
1. ESRD patients in our kidney center were more satisfied with their quality of life (QOL) than healthy subjects, and patients with transplants were the most satisfied of the three groups of ESRD patients. 2. About 40% of the ESRD patients were dissatisfied with their employment status. And about half of the patients who did not receive vocational rehabilitation could not find satisfactory employment. About 60% of the ESRD patients thought that they did not have the benefit of employment and were not satisfied with the work environment. 3. Most ESRD patients were dissatisfied with social services and were anxious about social insurance, especially their economic status.
Thus, ESRD patients were satisfied with their QOL, but were anxious about the future, especially their economic status and insurance, because they were dissatisfied with their work environment. In order to achieve satisfaction in ESRD patients, it is important to establish adequate social services and information concerning social services and insurance.

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Nursing care to aid social and mental problems, after due consideration of the patients' whole personalities, is necessary in patients with chronic hemodialysis. In this study, we arranged and analyzed systematically various information about patients. The subjects were ten patients undergoing chronic maintenance hemodialysis for about five years (from one month to fourteen years). Six patients were male and four were female. The average age was 55.9±9.8 years. The underlying diseases were chronic glomerulonephritis (n=9) and diabetes mellitus (n=1).
As analysis methods for information, we used the “Fish-bone” type analysis, “Sequence of events” (Hurst), egogram (TEG), and the “Cobweb” type of analysis. We discussed these methods in case conferences and performed mental nursing care according to the “Cobweb” type analysis.
As the nursing evaluation method, we applied “grief level” assessment of patients by Duke University Hospital. Therefore, we were better able to understand the mental states of patients and performed nursing care easily. After that, shock and depression of the grief level in patients decreased significantly, and patients were able to progress smoothly to the next step of acceptance and settle their problems or anxieties. United action in nursing care could be performed by repitition of conferences, and nurses could take care of patients with gentleness and understanding. Consequently, it seems that patients could better understand their physical and mental states and accept their new hemodialysis lives.

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The creatinine D/P ratio was measured in a patient undergoing monthly CAPD for 57 monthes, who experienced the complication of loss of ultrafiltration capacity. There was a negative correlation between creatinine D/P ratio and monthly ultrafiltration volume (r=-0.71). Based on the data of increasing creatinine D/P, it seems quite likely that performance of CAPD in such a patient will be impossible within a few years.

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High DLIS (0.50-0.77ng/ml) was detected in a hemodialysis (HD) patient who had been administered the Chinese medicine “Taisou ichyousan”. The man was 62 years old and had been on HD for about 2 years. Except for renal failure, the only complication was hypertention. No malignant tumors were detected from several examinations, so the origin of the DLIS was thought to be exogenous. Since DLIS decreased to under 0.2ng/ml after administration of the Chinese medicine was stopped, this drug was considered the cause of the DLIS. Extract from 1g of the Chinese medicine had a digoxin-like immunoreactivity equivalent to 156ng (TDX Digoxin II, Dainabot Laboratories). The estimation from the serum concentration, however, should have been about 10, 000ng/g, leaving a considerable gap between the actualy measured value and the estimated one. Such a contradiction might be explained by the theory that the bovine bile in this Chinese medicine (Taisou ichyousan) is changed to DLIS in the body following absorption.

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A 55-year-old man who had been on hemodialysis because of diabetic nephropathy was hospitalized with complaints of chest pain and fever. Admission blood tests showed a WBC of 13, 300/mm² and a CRP of 23.5mg/dl. An echocardiogram revealed mild pericardial effusion. Bacterial culture of the patient's blood and pericardial effusion were positive for Klebsiella pneumoniae.
Treatment by prompt pericardial drainage and antibiotic therapy was quite successful. Since, purulent pericarditis is known to be a rare and fatal disease, it is particularly important for physicians in clinical practice to be aware of this disease and make a prompt diagnosis, especially in dialysis patients.

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A 66-year-old man, who had been undergoing hemodialysis for 10 months, was admitted because of fever of unknown origin (FUO) and consciousness disorder. A chest roentgenogram on admission revealed diffuse illdefined or acinar shadows throughout both lungs. On the patient's 3rd hospital day, these shadows had become confluent and nodular shadows were present. Laboratory studies suggested the possibility of DIC, hepatic failure and respiratory failure. An electroencephalogram showed slow waves. The tentative diagnosis was miliary tuberculosis. Antitubercular agents were started on the 3 rd hospital day. The diagnosis of miliary tuberculosis was confirmed by pathological examination of a bone marrow aspirate. Despite the antitubercular therapy, the patient's respiratory failure and hepatic failure progressed, and he died on the 41 st hospital day. The association of miliary tuberculosis with multiple organ failure appears to be rare. This case, however, shows that an attempt to treat with antitubercular agents, i.e., so-called “therapeutic diagnosis”, is necessary for the antibiotic-resistant FUO in dialysis patients.

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A 25-year-old man with drug-resistant nephrotic syndrome due to focal glomerulosclerosis (FGS) exhibiting massive anasarca, renal dysfunction and marked hypercholesterolemia (544mg/dl) was treated by means of LDL-apheresis. Although the initial renal biopsy specimen showed minimal change-type lesions, the second biopsy specimen obtained after 2.5 months of unsuccessful treatment revealed typical FGS findings with focal segmental hyalinosis and sclerosis accompanied by lipid deposition in the involved area which was found to contain apoprotein B (apoB) by means of immunofluorescent microscopy. LDL-apheresis was performed twice a month using a dextran sulfate cellulose column (Liposorba LA-15) as the LDL absorber and polysulfone hollow-fibers (Sulflux) as the plasma separator, processing a total of 4, 000ml of plasma during each apheresis. Immediately after the start of treatment, the patient's renal dysfunction improved and increased creatinine clearance and decreased urinary protein were observed. After each treatment serum levels of LDL and apoB decreased to 39.7±8.7% and 45.5±17.0% of their pre-treatment levels, respectively. HDL-cholesterol (HDL-C) and apoA1, on the other hand, decreased to only 87.2±14.4% and 82.2±14.4% of their initial levels, respectively. Relatively smaller decrements in HDL-C and apoB levels reduced the atherogenic index and apoB/apoA1 ratio. Although each apheresis was effective enough to reduce serum LDL levels, performance twice a month was not frequent enough to maintain serum cholesterol at low levels continuously, and deterioration of the patient's nephrotic syndrome occurred. In order to suppress the recurrent cholesterol elevations, pravastatin, an HMG-CoA reductase inhibitor, was administered.
As a result of this combined therapy, cholesterol levels became permanently lower than 200mg/dl, and the nephrotic syndrome remitted with an increase in calculated LDL-receptor activity and the intermediate-density lipoprotein index.
The rapid and constant lowering of high serum levels of LDL by LDL-apheresis in combination with a lipidlowering agent, appeared to be effective in improving secondary glomerular injury due to LDL in drug-resistant nephrotic syndrome associated with severe hypercholesterolemia.

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A case of a 48-year old man with consciousness disorder and acute renal failure due to lymphomatous infiltration is reported.
The patient was admitted to our hospital because of high fever, consciousness disorder and acute renal failure. His blood pressure was 122/86mmHg, and he fell into drowsy state. Cervical lymphadenopathy and anisocoria were present, but there was no hepatosplenomegaly. Laboratory findings on admission were as follows: Hb 13g/dl RBC 401×10⁴/cm², Plt 4.2×10⁴/cm², GOT 78 KU, GPT 10 KU, LDH 2, 926 WU, BUN 131mg/dl, Cr 14.3mg/dl, Blood gas analysis revealed metabolic acidosis. Urinalysis was positive for proteinuria. Bone marrow aspiration and lymph node biopsy revealed diffuse infiltration by large lymphoma cells. Abdominal sonography showed diffusely enlarged kidneys. There was no evidence of hydronephrosis. The patient was treated with prednisolone and vindecine and by hemodialysis. A rapid improvement in the patient's renal function and consciousness was observed. Five months after admission, however, he died of tonic convulsions. Autopsy of the kidney and liver showed diffuse infiltration by lymphoma cells.

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The patient was a 54-year-old woman who had received injuries to the right forearm and elbow on December 25, 1987. She sought treatment at a hospital and the wound was disinfected and sutured. The patient became unable to open her mouth, suffered convulsions of the trunk and developed neck stiffness on January 1, 1988. She was admitted to the same hospital and diagnosed as having tetanus on January 4. The patient was so incapacitated that she had to be transported to our hospital and admitted to the ICU on January 5. After muscle relaxants had been administered, nasal intubation was performed. The patient's renal function gradually, deteriorated and we decided to treat her by hemodialysis. We were unable to continue this treatment because of a sudden hypotensive state due to sympathetic hyperactivity, so we treated her by peritoneal dialysis using an automatic peritoneal dialysis cycler (APD cycler) beginning on January 15. No problems or major complications were observed during the procedure. The patient's renal function recovered completely, and we discontinued peritoneal dialysis on February 23. The patient was discharged from our hospital on August 10 and returned to work with no sequelae. We briefly discussed the effect of peritoneal dialysis using the APD cycler and emphasized the usefulness of this treatment in such sympathetic hyperactive states of tetanus.

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A 46 year old female was admitted for evaluation of paresthesia and weakness of extremities and pretibial edema. She was diagnosed as having Crow-Fukase syndrome because she had cutaneous hemangioma, hypertrichosis, hypothyroidism, general edema, ascites, pericardial effusion, polyneuropathy, splenomegaly and IgA-λ type M-protein. Twenty-five days after admission anasarca worsened and renal function declined rapidly. Thirtyfive days after admission hemodialysis was initiated to manage anasarca and renal function. The results of blood examination at the beginning of hemodialysis were as follows; BUN; 135mg/dl Cr; 4.5mg/dl, K; 6.6mEq/l Corticosteroid therapy was also started. Three days after the initiation of hemodialysis, urine volume began recovering rapidly. Corticosteroid therapy, including pulse therapy, was effective in the recovery of renal function and in reducing other symptoms. Percutaneous renal needle biopsy was performed when serum creatinine had returned to the normal level. Renal histology showed thickening of the glomerular capillary wall and an expanded subendothelial area with deposition of amorphous materials. Crow-Fukase syndrome is a rare disease characterized by general edema. Although renal dysfunction was noticed recently the degree of renal impairment is usually modest. We report here a case of this syndrome who had severe renal dysfunction and who was treated successfully with hemodialysis and corticosteroids.

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A 45-year-old male patient, maintained on hemodialysis for 3 months, was referred to our department for acute left abdominal pain. Left renal arteriography revealed three aneurysms in a branch of the left renal artery and leakage of contrast medium from one of them. Exploration was done through a left lumber approach and the hematoma, including the left kidney, was removed. Rupture of the aneurysm was diagnosed macroscopically. There have been 10 reported cases of retroperitoneal hematoma in the setting of hemodialytic therapy, including the present case, in Japan and we have discussed the pathogenesis and treatment of this rare disease.

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A 45-year-old male patient with CRF undergoing CAPD was admitted to our hospital in March 1988 because of bloody peritoneal effluent due to blastic crisis of coexisting chronic myelogenous leukemia (CML). He was started on HD in August 1982, and switched to CAPD in June 1983, when he was found to have associated CML Chemotherapy with busulphan was started in December 1983 and hematologically successful effect was obtained. Thereafter was CAPD carried on with no major problems until the admission. On admission, marked splenomegaly was noted. His laboratory data revealed a prominent increase inblastic cells in both peripheral blood and bone marrow confirming the diagnosis of CML Immediately after admission he was treated initially with 6MP, and then with VCR and PSL with no benefical response. He died of fungal peritonitis in June 1988. He survived for so long as 5 years undergoing CAPD after the diagnosis of CML.

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We report the case of a 56-year-old man who died of perforation of the caecum-ascending colon secondary to diverticulitis. His presenting symptoms were intermittent abdominal pain, vomiting and anorexia. We performed a gastroendoscopic examination and found acute erosive and hemorrhagic gastroduodenitis. Intravenous hyperalimentation and medication were initiated. One week after the onset, he showed symptoms of peritonitis and paralytic ileus. Because of his mental retardation, we encountered difficulties in diagnosing his condition. We emphasize that the prognosis of diverticulitis of the colon in patients undergoing hemodialysis is grave.

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