Between January, 1985, and January, 1990, we encountered 3 patients who had been undergoing LDL-apheresis (LA) for 5 years, 3 years, and 2 years 10 months, respectively. We evaluated the incidence of hypotension and factors involved in its etiology during LA. Extracorporeal blood volumes were about 600ml in the LA-40 system and about 350ml in the LA-15 system. Average systemic blood pressures measured at 6 month intervals decreased more with the LA-40 system than the LA-15 system, while body weights increased 0.59kg with the LA-40 system and 0.33kg with the LA-15 system. The incidence of hypotension with systolic blood pressure under 100mmHg continuing for over 20 minutes was also lower with the LA-15 system than the LA-40 system.
We evaluated C_3a, C_5a, polymorphonuclear leukocyte elastase, atrial natriuretic peptide, cathecholamines, etc., but there was no evidence of any relationship between extracorporeal hypotension and these humoral factors without serotonin.
We believe that the pathophysiology of hypotension in patients undergoing LA is symptomatic since hemodialysis patients develop it during hemodialysis. It is very important to prevent this hypotension by using the LA-15 system on familiar in hypercholesterolemia patients who have severe ischemic heart disease as early as possible.

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We encountered three cases of hypothyroidism in female chronic renal failure patients. Case 1 was diagnosed as transient hypothyroidism because the patient's thyroid function became normal after beginning hemodialysis without I-thyroxine therapy. Case 2 consisted of primary hypothyroidism due to Hashimoto's thyroiditis. At first the patient required a great deal of I-thyroxine, but after one year of regular hemodialysis her symptoms improved on reduced doses of I-thyroxine. In Case 3 there were low levels of serum TSH and thyroid hormones and a lack of TSH response to TRH. This patient's thyroid function and clinical symptoms responded to oral administration of TRH derivatives and regular hemodialysis, and a hypothalamic-pituitary axis abnormality was suggested.
In conclusion, it is difficult to precisely assess thyroid function in patients with end-stage renal failure on the basis of serum thyroid hormone levels and clinical symptoms, because hypothalamo-pituitary-thyroid dysfunction may occur in severe uremic states. Consequently, it should be emphasized that thyroid function and compensatory doses of I-thyroxine must be re-evaluated after improvement in patients' metabolic state by hemodialysis.

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To examine the effect of weight gain between routine dialysis sessions regarding the progression of left ventricular hypertrophy without the influence of anemia, 22 patients on regular hemodialysis therapy with hematocrit values ranged 20 and 25%, were investigated using M-mode echocardiography. The patients were divided into 2 groups according to the degree of weight gain (weight gain/dry weight). Eight patients were placed in group 1 (weight gain≥5.0%) and 14 were placed in group 2 (weight gain<5.0%).
Systolic and diastolic blood pressure were also evaluated as other factors influencing left ventricular hypertrophy. Left ventricular mass index (LVMI) in group 1 was significantly larger than LVMI in group 2 (154.8±48.3g/m² vs 115.7±18.7g/m², p<0.01). A significant positive relationship was observed between the weight gain rate and LVMI in all patients (r=0.75, p<0.001). The systolic and diastolic blood pressure were similar between the two groups.
These results suggest that maintaining a small weight gain may be important in preventing the progression of left ventricular hypertrophy in chronic hemodialysis patients.

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The relationship between degree of coronary occlusion, based on the results coronary arteriography, and lipids, particularly serum Lp (a) lipoprotein, was examined in chronic hemodialysis patients.
Coronary arteriography was performed on 16 men undergoing chronic hemodialysis at our hospital who exhibited cardiac symptoms and ischemic changes on ECG. The degree of coronary occlusion was determined on the basis of the Gensini score and Lp (a) assay by ELISA.
There was a statistically significant positive correlation between the Gensini score and Lp (a) level, with a correlation coefficient of r=0.50 (p<0.05). There was also a positive correlation between total cholesterol level and the Gensini score, with an r=0.59 (p<0.05). No correlation, however, was found between the Gensini score and triglycerides, HDL-cholesterol, VLDL, LDL, Apo A₁, A₂, B, C₂, C₃, E, atherogenic index, mean blood pressure, Brinkmann index, or Broca index.
The coronary artery occlusion score was positively correlated with serum Lp (a) and total cholesterol levels, and the correlations were statistically significant, however, no correlations with other lipids, apoproteins or coronary risk factors were detected. Lp (a)should be considered a coronary risk factor in maintenance hemodialysis patients with chronic renal failure.

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In a CAPD patient with diet-induced chyloperitoneum, we studied the effect of oral intake of long-chain triglycerides (LCT) and medium-chain triglycerides (MCT) on the components of the peritoneal dialysates. After 6.5-48 hours, LCT induced milky ascites which were rich in triglycerides, chylomicrons and total lipids. However, LCT did not induced the milky appearance. The oral intake of LCT appeared to be an important factor which causes milky ascites in our patient.

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In order to clarify the cause of enhanced fibrinolytic activity during hemodialysis (HD), the fibrinolytic activity was evaluated in 15 patients undergoing regular dialysis treatment (RDT) using new parameters including α₂-plasmin inhibitorplsmin complex (α₂PIC), tissue plasminogen activator (t-PA) antigen, plasminogen activator inhibitor-1 (PAI-1) antigen and von Willebrand factor (vWF) antigen, which is regarded as reflecting a release reaction to certain stimuli by the vascular endothelial cells. Furthermore, controlled cross-over investigations were performed to rule out the effect of heparin administration. During a single HD session, α₂PIC exhibited a continuous, significant increase. The t-PA antigen significantly increased during HD, and the PAI-1 antigen significantly decreased during HD. The vWF antigen also significantly increased during HD. But heparin administration alone did not induce any significant increase in the α₂PIC or t-PA antigen of RDT patients. An increase in the release of t-PA with the consumption of PAI-1 is likely to be a leading cause of enhanced fibrinolytic activity during HD. Our observations demonstrated negative results regarding the effect of heparin administration on enhanced fibrinolytic activity during HD.

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Destructive spondyl-arthropathy (DSA) in long-term hemodialysis (HD) seems to be associated with local amyloid deposits due to dialysis amyloidosis. We performed X-ray examinations of DSA in 129 patients on reguler dialysis in our hospital. Nineteen patients (14.8%) had narrowing of intervertebral discs without sign ificant osteophytosis.
The patients were divided into four stages; Stage 1: 11 (8.5%), narrowing of the inter-vertebral disc, Stage 2: 6 (4.7%), severe narrowing of the intervertebral disc and osteosclerosis, Stage 3: 2 (1.6%), erosions and geodes of the adjacent vertebral plates, and Stage 0: 14 (10.9%), patients on long-term (10-years or longer) HD without arthrosis. There was no significant difference in biochemical parameters; HS-PTH, AI, β₂-micro-globulin (β₂-MG). There were, however, significant differences in the duration of HD; Stages 2 and 3: 125±47 (45-185) months, Stage 1: 78±46 (3-147) months, Stage 0: 180±30 months, and in age; Stage 0: 46.8±7.9 y, Stage 1: 48.5±9.0 (36-66) y, Stages 2 and 3: 54.6±7.1 (43-63) y. These studies suggest that DSA correlates with age-related bone loss or age-related amyloidosis and long-term hemodialysis.
Magnetic resonance imaging (MRI) study of DSA is useful for diagnosing progression of the narrowing of the intervertebral disc space and compression of the spinal cord. In conclusion, DSA progression initiates from the narrowing of inter-vertebral disc.

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In order to determine the efficacy of immunoadsorbent therapy (IAT) in immunoneuropathies, we performed IAT on five patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) who had failed to respond to drug therapy and one patient with Guillain-Barré syndrome (GBS). IAT was administered as follows: an ethylenevinyl-alcohol hollow fiber was used as the membrane plasma separator, and a column characterized by the attachment of phenylalanine to porous polyvinyl-alcohol gel served as the plasma adsorbent column. IAT was performed between one and thirty-five times, depending upon the patient's condition. An improvement in subjective symptoms was observed in every case. The efficacy of IAT was objectively demonstrated by an increase in grip strength and improvement in gait. Changes in plasma protein fractions as a result of IAT were also investigated, and significant decreases in immunoglobulin fractions were detected. Abnormal increases in cerebrospinal fluid protein concentration in CIDP also improved after IAT. Transient hypotension and fever were observed, however, neither was serious or resistant to treatment. Thus, the present study suggests that IAT may be an effective and safe method of treating patients with immunoneuropathies.

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This study was designed to assess autonomic nerve function in hemodialysis patients by the method of measuring amounts of Mayer wave sinus arrythmia (MWSA) and Respiratory sinus arrythmia (RSA) as evaluated by autoregressive spectral analysis of heart rate variability. MWSA and RSA probably reflect sympathetic nerve and parasympathetic nerve functions, respectively, on the heart.
Thirty-three hemodialysis patients and 10 healthy controls were chosen as the subjects of this study. ECG was recorded for 5 minutes in supine and standing positions, then MWSA and RSA were evaluated following autoregressive spectral analysis corresponding with the time series of the ECG R-R interval. To assess these individual components, a parameter termed the component coefficient of variance (C-CV) was employed, and compared with the coefficient of variance of the R-R interval (CV-RR).
It was demonstrated that hemodialysis patients had significantly lower levels than normal controls in C-CV_MWSA, C-CV_RSA and CV-RR in both supine and standing positions (p<0.01). With postural change from the supine to the standing position, the control group showed a significant increase in C-CV_MWSA (p<0.05) and a significant decrease in C-CV_RSA (p<0.01). On the other hand, the hemodialysis group showed no significant changes in C-CV_MWSA and a significant decrease in only C-CV_RSA (p<0.05). The conventional mesuring method of CV-RR was unable to detect variation by means of postural changes.
In relation to the duration of hemodialysis, the group which had over 10 years of hemodialysis demonstrated significantly lower levels of C-CV_MWSA in the standing position as compared with the group which had less than 5 years of hemodialysis (p<0.01). C-CV_MWSA, in the standing position, was diminished in proportion to the duration of hemodialysis.
In relation to blood pressure, hypotensive patients showed lower levels of C-CV_MWSA and C-CV_RSA as compared with nonhypo-and hypertensive patients.
Thus, we conclude that chronic hypotension in long-term hemodialysis patients may be due to hypofunction of the sympathetic nervous system, and also low responsiveness of sympathetic barorecepters.

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We evaluated autonomic functions by means of cold pressor, norepinephrine and atropine tests in twelve patients undergoing regular hemodialysis (six patients were diabetic). Five of seven patients (including five diabetic patients) having orthostatic hypotension showed abnormal responses to the cold pressor test. After norepinephrine injection, these seven patients showed hyper-reactive responses, similar to the responses of patients with denervation super-sensitivity. These results indicate that disturbance of postganglionic sympathetic neurons could be involved in the pathogenesis of orthostatic hypotension in patients on regular hemodialysis. When atropine, a muscarinic acetylcholine blocker, was injected, four patients with orthostatic hypotension presented sympathetic signs, although an increase in heart rate was not observed. These observations indicate that a parasympathetic fiber disorder could also contribute to the pathogenesis of the orthostatic hypotension. Based on these findings, in order to prevent orthostatic hypotension, we tried to educate the patients and instructed them as to appropriate daily behavior. In addition, we monitored blood pressure as well as EGG during hemodialysis as part of the management of patients with orthostatic hypotension, because the heart rate did not increase even when hypovolemic shock ensued in these patients. Four patients exhibiting orthostatic hypotension and postganglionic sympathetic nerve disorders were treated with midodrine, a specific α₁ receptor stimulator, in order to prevent orthostatic hypotension after hemodialysis treatment. These maneuvers were useful for the management of the orthostatic hypotension.

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One hundred seven patients (65 males and 42 females) out of 187 patients treated by means of hemodialysis have been sampled to investigate correlations between pain grade score, bone microdensitometry (MD) parameters and blood biochemical studies. The patients were divided into the following 4 groups on the basis of pain grade score, Group 1, pain score 0; Group 2, pain score 1-7; Group 3, pain score 8-14; Group 4, pain score more than 15 points. Both age and duration of hemodialysis were greater in Group 4 than in any other pain score group. MD parameters were positively correlated with all of the pain groups. We were unable to detect any significant correlation between AI-P, or β₂-MG and pain groups. C-PTH, HS-PTH and BGP (osteocalcin) levels in Group 1, the pain-free group, were higher than in any other pain score group. Parathyroidectomy (PTX) was performed in 10 cases, and with the exception of these 10 cases, serum levels of C-PTH, HS-PTH and BGP were examined, and the results were the same. The serum AI levels in Group 4 were the highest in all of the pain score groups. This suggests that long-term hemodialysis might result in low bone turnover. We conclude that MD parameters and pain grade score are useful in following ROD in long-term hemodialysis patients.

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Calcium carbonate (CaCO₃) is widely used as a phosphate binder for dialysis patients. The plasma calcium (Ca) in CARD is maintained at the upper normal limit. Therefore, any additional dosage of vitamin D or CaCO₃ must be restricted. A low Ca dialysate of Ca 2.3mEq/l (LCa) was prepared and examined by the equilibration test. It was then compared with ordinary dialysates: Ca 3.5mEq/l (DCa 3.5) and 4.0mEq/l (DCa 4.0). Mass transfer of Ca per day was positive and normal for DCa 4.0 (31±51mg/day) and DCa 3.5 (-37±40mg/day) but negative for LCa (-157±26mg/day). The low Ca dialysate was used in 6 cases (4 of high PTH, 2 of high phosphathemia) that had been difficult to control by ordinary dialysate. After 6 months, the dosage of CaCO₃ and vitamin D were able to be increased from 1.2±1.5 to 5.4±3.3g/day (p<0.05) and from 0.17±0.2 to 0.38±0.47μg/day, respectively, and aluminum-gel, to be terminated completely. Plasma Ca and phosphate were well controlled. The low Ca peritoneal dialysate is likely to become the standard dialysate.

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High-dose methotrexate (MTX) therapy has been proposed to be effective for the treatment of osteosarcoma. However, it frequently induces acute renal failure (ARF). Since the drug is excreted mainly through the kidney, MTX-induced ARF per se also contributes to the retention of MTX, thereby enhancing side effects of the drug other than ARF. Therefore, it is mandatory to attempt to eliminate MTX particularly in ARF. In our recently experienced MTX-induced ARF, direct hemoperfusion (DHP), hemodialysis (HD) and/or plasma exchange (PE) were performed singly or in combination. Better elimination rates were obtained in the order of PE, DHP+HD, DHP and HD. However, more marked decline of serum MTX was noted along with increased urine volume and decreased serum creatinine. Although it is clear that intact renal function exceeds any of the blood purification means in terms of MIX elimination, these attempts should be made to minimize the side effects particularly when renal function is impaired.
Of the 3 methods we have herein applied, PE seems to be the most effective. However, PE is not recommended in view of the hazard of infection such as hepatitis virus and also from a socioeconomical perspective. DHP combined with HD, therefore, is preferable to PE.
Therefore, we propose that in ARF, repetition of DHP plus HD shoud be introduced in order to minimize the side effects of MTX.

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To clarify the effects of recombinant erythropoietin (rEPO) treatment (Tx) in hemodialysis patients (Pts) with iron overload, we examined the body iron status of 10 regular hemodialysis Pts with high serum ferritin concentrations (800-2, 144ng/ml). They were receiving 1, 500 or 3, 000 units of rEPO three times weekly, and when their hematocrits (Ht) reached 25-30%, the rEPO was diminished. The serum iron (Fe), unsaturated iron binding capacity (UIBC), transferrin saturation (Fe divided by total iron binding capacity, TFS), and serum ferritin concentrations were measured.
Results: 1. The Ht increased from 17.1±2.7% to 26.0±3.9% after three months of rEPO Tx. 2. Six of the ten Pts (60%) showed relative iron deficiency, defined as Fe<60μg/dl, UIBC>60μg/dl, and TFS<25%, but the high serum ferritin concentrations, and simultaneously their rates of increasing Ht slowed. 3. After iron supplementation, their hematopoietic responses were improved. 4. The mean serum ferritin concentrations decreased from 1, 449±413ng/ml to 367±172ng/ml after 30 months of rEPO Tx.
Conclusion: The relative iron deficiency was observed in several iron-overloaded Pts during rEPO Tx. In these Pts, the mobilization from stored iron to available iron may be poor and/or slow. With a view to the effective use of expensive rEPO, it seems that limited iron supplementation is necessary therapy for relative iron deficiency during rEPO Tx in iron-overloaded Pts.

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It is impossible to monitor the dosage of low molecular weight heparin (LMH) during hemodialysis by conventional coagulation tests which are utilized in cases of unfractionated heparin. The usefulness of the reaction time on thrombelastography (TEG-r) and whole blood Xa coagulation time (XaCT) for this purpose has been reported. The aim of the study is to compare the efficacy of coagulation tests for dosage monitoring of LMH during hemodialysis with respect to sensitivity. We measured TEG-r, XaCT, plasma heparin concentration (anti-Xa activity) and activated partial thromboplastin time (APTT) using the same samples obtained from seven patients (4 men and 3 women, aged 24-74 years) during hemodialysis. When a cut-off value for each test was determined so as to make the degree of dialyzer residual blood minimal in all LMH doses of the patients, the correlation between the results and the degree of residual blood was significant noly in TEG-r. ‘Sensitivity’ and ‘negative predictive value’ for prediction of the degree of residual blood were 69% and 67% in TEG-r, 46% and 53% in XaCT, 38% and 50% in plasma heparin concentration, and 23% and 44% in APTT. The degree of change in results in response to a 100U change in LMH dosage were as follows; greater than 20 increases in the minimal unit in terms of measurement of TEG-r, APTT and XaCT and an 8 fold increase in plasma heparin concentration. These results suggest that TEG-r is the best method for LMH dosage monitoring during hemodialysis among the four coagulation tests investigated. The XaCT may be a useful method as well, particularly because of its feasibility at the bed-side. We consider TEG-r to be superior to the other tests because it is measured using whole blood without addition of coagulation-inducing substances.

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We report the dynamics of oxygen radical generation by polymorphonuclear leukocyte (PMNs) in hemodialysis (HD) patients. Oxygen radicals were monitored by luminol-enhanced chemiluminescence (CL) utilizing purified PMNs and microamounts of whole blood. Different CL patterns were observed depending on the mechanisms of different stimulants, such as phorbol myristate acetate (PMA), A23187 and opsonized zymosan (OZ).
The key findings were as follows. In comparison with healthy controls CL intensity was impaired in HD patients when PMA stimulation was used but not A23187 or OZ. It was also found that the longer the period of hemodialysis, the greater the decrease in CL intensity became. There was a significant positive correlation between maximum CL intensity with purified neutrophils and whole blood when stimulated by PMA and OZ. In HD patients, time to peak (Tmax) and time to half-peak (T1/2max) CL intensity decreased in the case of PMA stimuulation but increased in the case of OZ stimulation.
These results suggest that the PMNs of HD patients are prepared to generate oxygen radicals rapidly when stimulated at proteinkinase C, but that receptor-mediated activation is suppressed, probably due to chronic stimulation by uremic toxins or the HD procedure itself. The duration of HD must be taken into consideration when assessing the results of CL studies. The whole-blood method is useful in assessing the CL of PMNs, since it provides a more physiological approach to testing PMN function, avoiding the if not purified effects of blood purification, etc.

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Recently, plasma atrial natriuretic peptide (ANP) concentration has been shown to be a potential index of fluid retention in patients on maintenance hemodialysis (HD). The present study was undertaken to evaluate the relationship between plasma ANP concentration, diameter of the inferior vena cava during expiration (IVC-E), and circulating blood volume (CBV).
Thirty-seven HD patients were studied before and after HD. Plasma ANP concentrations measured using a specific and sensitive radioimmunoassay, were far above the normal range before HD. After HD, plasma ANP concentrations decreased, but the average remained above the normal range (147.7±9.0→126.9±12.0pg/ml, p<0.05). There was a weak correlation between plasma ANP levels and changes in the ratio of body weight to dry weight. The rate of ANP decrease was significantly correlated with that of IVC-E (y=0.587x+7.538, r=0.477, p<0.05, n=16). Changes in CBV paralleled those of IVC-E.
Patients were divided into 3 groups on the basis of their, i.e., ANP levels, normal, moderately high and extremely high. Although ANP levels were unchanged in the normal group, ANP reductions were marked in the moderately high and extremely high groups in response to the same degree of fluid removal. There were no significant differences in CTR or mean blood pressure among these patients.
On the basis of these results, it was concluded that the changes in ANP concentrations might be a reflection of changes in CBV in patients on maintenance hemodialysis. They may also be useful in estimating fluid retention and fluid distribution.

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CHDF was performed on thirteen critically ill patients between October, 1989 and June, 1990. The priming volume of CHDF was so small that it did not affect the hemodynamic state of the patient. In addition, CHDF had superior ability to maintain acid-base balance, to correct electrolyte imbalances and to remove metabolic waste products as compared to continuous hemofiltration (CHF). Therefore CHDF can be applied even to hemodynamically unstable patients and children suffering from a variety of pathophysiological conditions. CHDF was found to be very effective in the treatment lactic acidosis, hyperammonemia and hyperpotassemia among such patients. We conclude that even though the system of CHDF is a little more complicated than that of CHF, CHDF is the blood purification of first choice for critically ill patients.

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Approximately a half of the deaths reportedly in patients on long-term maintenance hemodialysis is known to be related to cardio-or cerebrovascular lesions. In these patients, arteriosclerosis progresses with chronological age. As arteriosclerosis has already been pointed out to have an intimate relation with abnormalities in lipid metabolism in the non-uremic population, the metabolic state of lipids was investigated in maintenance hemodialysis patients. Blood levels of total cholesterol, HDL cholesterol and LDL cholesterol were assessed in 163 patients who were divided according to sex and hemodialysis period (HP) (HP≤60 mos, 60 mos<HP≤120 mos and 120 mos<HP). Results are as follows: 1. There was no definite tendency for abnormality in lipid metabolism in an average, among all patients, 2. the prevalence of abnormality in a total cholesterol level was high in patients on longer HP, especially in female patients, 3. the prevalence of abnormality in a HDL cholesterol level is high in male patients on longer HP and 4. the prevalence of abnormality in LDL cholesterol level is high especially in female patients on longer HP. Removal of LDL cholesterol utilizing an LDL adsorption system simultanuously with hemodialysis in two patients who had coronary ischemic lesions proved to be clinically effective.
We conclude that as the prevalence of dyslipidemic patients increases with longevity of hemodialysis, especially in females. Aggressive treatment of abnormal lipid metabolism is mandatory in order to obtain better prognoses in maintenance hemodialysis patients.

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It is important to select better arterio-venous fistula needles for hemodialysis in order to prolong the life span of shunts and to efficiently carry out hemodialysis. We set up an in vitro blood circuit composed of two needles at both ends of a blood line for hemodialysis and circulated heparinized bovine blood with a blood pump. The pressures at both arterial and venous sides were measured while the blood flow was set at 100, 200, or 300ml/min. About 40 needles including shortened needles and newly developed needles [25mm long 17 G (OD 1.34mm, ID 1.05mm) teflon needles with 4 side holes with a tube for clamping] were measured for pressure. The pressure at the venous side with 16 G needles at 200ml/min varied from needle to needle with a maximum of 97mmHg and a minimum of 55mmHg; the pressure of each metal needle was lower than that of any resin needle with a mean difference of 20mmHg. The increase in pressure (venous or arterial in particular) by changing the gauge from 16 G to 17 G could be offset by decreasing the length of a 17 G needle by 38%. Our newly developed 17 G needle had an arterial pressure similar to that of a 16 G needle. Needles with smaller diameter, which were considered to be better for the life span of the arterio-venous fistula than those with larger diameter, had higher pressures. This adverse effect of the needles with smaller diameter could be offset by shortening them.

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Elderly patients on long-term hemodialysis because of end-stage renal disease requiring surgery under general anesthesia are increasing in number. They are at high risk for surgery and frequently have postoperative psychiatric problems.
We encountered two elderly hemodialysis patients who complaining of psychiatric symptoms after surgery under general anesthesia, and re-evaluated their nursing care.
The first patient was a 62-year-old man on long-term hemodialysis. Gastrectomy was performed because of gastric cancer, and the patient complained of severe lumbago and became confused postoperatively. The second patient was a 73-year-old woman on long-term hemodialysis who was admitted to our kidney center because of severe GI bleeding. Surgery was performed, and the patient was disoriented postoperatively. We considered the psychiatric signs in these cases to be expressions of the patients' anxiety and physical pain, and found that the symptoms disappeared when the limitations on patients' movements and oral intake became less restricted. For nurses, the important thing, especially in the care of elderly hemodialysis patients who have undergone surgery, is to identify psychiatric symptoms and to understand what they mean. The relief of anxiety and pain must be accomplished against a background of good personal relationships with patients and their families.

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Peritoneal fluid drained from 2 patients undergoing continuous peritoneal dialysis became turbid after oral administration of a new dihydropyridine type of calcium channel antagonist, manidipine hydrocloride. Neither clinical nor laboratory findings suggestive of infectious peritonitis were observed. Biochemical analysis of the fluid revealed elevated triglyceride concentrations which were greater than those of clear peritoneal fluid.

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Serum cardiac myosin light chain I (MLC I) levels were determined using anti-LC I monoclonal antibodies in 12 patients on maintenance hemodialysis therapy (HD) and 11 healthy controls.
The mean levels (±SD) of MLC I were significantly higher in HD patients than in the controls (9.43±5.48ng/ml vs less than 2.5ng/ml, p<0.01). MLC I levels of HD patients were significantly increased by HD (9.43±5.48ng/ml vs 11.84±6.09ng/ml, p<0.01) but there was no significant difference between MLC I/TP before and after HD (1.42±0.78 vs 1.50±0.61).
MLC I was positively correlated with β₂-MG in HD patients (r=0.66, p<0.02).
These data suggest that the elevation in MLC I levels in HD patients is related to impairment of its dialyzability.

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The clearance of a new antiarrhythmic agent, cibenzoline succinate (cibenzoline), during hemodialysis (HD) was evaluated in 7 HD patients. Plasma concentrations of cibenzoline after oral administration of 100mg of the drug were evaluated by means of high-performance liquid chromatography. Patients were dialyzed with a 200ml/min blood flow and 500ml/min of dialysate. Average clearance of the agent was 60.0±9.6ml/min (mean±SD), and this was equivelent to 41.0±7.3% of the creatinine clearance or 48.1±8.3% of the BUN clearance measured simultaneously. Although the plasma concentration of cibenzoline exceeded the minimum effective level of 250ng/ml during the first half of the HD procedure, it then tended to decrease to below the effective level during the latter two-third of the HD period in all cases. This indicates that supplementary doses of the agent are needed during HD to treat the arrhythmias which frequently occur later in HD.

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We encountered two cases that showed a marked change in the facial contour due to enlargement of the jaw bones during long-term hemodialysis therapy. This paper is a report of our findings.
Case 1 is a 48-year old man with 10 years' history of hemodialysis. From around the 7th year of dialysis, there appeared ostalgia starting from the ankle. Thereafter, the jaw bones became enlarged with swelling at the tips of the fingers, hunchback and narrowing of the chest. This has since increased to bring about a marked change in the facial countour. Biopsy of the maxillary bone showed fibrous osteitis. AI-P and C-PTH levels were high at 84.0 KAU and not less than 76.8ng/ml respectively. Ultrasonography showed swelling of the parathyroid glands. Under the diagnosis of 2°HPT, parathyroidectomy was performed. As a result, the tendency of the jaw bones to enlarge was slightly moderated.
Case 2 is a 31-year old woman with an 8-year history of hemodialysis. From about the 5th year of dialysis, ostalgia appeared starting from the sole. Thereafter, the jaw bones began to enlarge with the same symptoms as in case 1, which resulted in a change in the facial contour. The AI-P and C-PTH levels were high at 80.3 KAU and not less than 76.8ng/ml. Ultrasonography showed swelling of the parathyroid glands.
The control of Ca and P was very poor, suggesting a relationship between the poor control of C and P and the development of this disease.

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A 47-year-old man undergoing CAPD for 16 months was admitted because of peritonitis. Intraperitoneal injection of antibiotics was not effective. Six days later, chest X-ray revealed a right-sided dominant hydrothorax, and abdominal ultrasonogram revealed a right-side subphrenic abscess. The peritonitis became increasingly severe and was finally intractable. To investigate the pathogenesis of pleural effusion, Indocyanine Green was infused into the abdominal cavity, and pleuroperitoneal communication was demonstrated. After thoracotomy and interruption of CAPD, the peritonitis subsided, together with complete disappearance of pleural effusion. We assumed this pleural effusion to be a direct inflammatory spreading from the abdominal cavity.

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A 34-year-old man on hemodialysis therapy for 8 years suffered severe hyperparathyroidism accompanied by a reduction in body height of approximately at 23cm. Parathyroidectomy was indicated in this patient, and he was subsequently followed for three years. The patient regained about 3cm in stature, and ectopic soft tissue calcification partially disappeared. His recovery of body height was attributed to improvement in his kyphosis on the basis of spinal measurements.

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We formerly reported that hyperosmolar hemodiafiltration with hypertonic alkaline supplementation (modified biofiltration) was more effective for removing small and middlesized molecules than conventional hemodialysis. A hemodialysis patient with anemia, who was resistant to recombinant human erythropoietin (rEPO) treatment, was treated by the modified biofiltration method. Though this patient received intravenous injections of rEPO at a dose of 1, 500 U after each hemodialysis treatment thrice weekly for 11 weeks, her anemia remained unchanged (RBC 186×10⁴/mm³, Ht 19.4%, Hb 6.1g/dl). As a result, it was decided to try modified biofiltration instead of conventional hemodialysis. Two weeks after rEPO was injected at the original dosage (1, 500 U), RBC, Ht and Hb began to increase, and both serum iron level and ferritin level decreased. At 17 weeks, RBC, Ht and Hb reached levels of 308×10⁴/mm³, 30.0% and 9.5g/dl, respectively. Modified biofiltration was performed for 14 weeks. As for side effects, it was anticipated that a gain in predialytic body weight due to drinking large quantitics of water and excessive alkalosis would appear. However, the only side effect the patient experienced was a slight thirst. We supposed that RBC production in response to rEPO administration was mainly diminished by uremic toxins rather than inadequate rEPO dosage. From this standpoint, modified biofiltration was effective for improving anemia in this patient. These results demonstrate that new techniques which help rEPO supplementation therapy in hemodialysis treatment have to be devised in the future. These new treatments in hemodialysis can reduce the use of rEPO.

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A 57-year-old female on chronic hemodialysis was diagnosed with HTLV-1-associated myelopathy (HAM). She had received over 4, 200ml blood infusion during her initial hemodialysis period. After a year, pollakisuria, residual urine sensation and residual urine appeared. Five years later, she had gait disturbance. Eight years later, sensory disturbance appeared in her lower extremities. These symptoms were eventually complete. Laboratory data revealed that the serum anti-HTLV-1-antibody was over x 256 (PA), liquor anti-HTLV-1-antibody was over x 36 (PA). The patient's lymphatic function test showed a remarkable decrease in OKT 4/OKT 8 of 0.53. Treatment was initiated with a 600mg daily dose of Erythromycine. Symptoms inproved with therapy. The OKT 4, OKT 8 ratio showed an incremental tendency to ward normal. To our Knowledge, there are no other case reports concerning HAM among hemodialysis patients, in spite of many blood transfusions over the past dozen years. At present, in patients with HAM, OKT 4/OKT 8 rise as a consequence of active helper T-cells. This suggests that hemodialysis patients could take a clinical course different from that of others.

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