[in Japanese]

View full abstract

The outcomes of diabetic patients on dialysis have been poor. Early death from cardiovascular causes occurs frequently. We recently studied the incidence and features of acute myocardial infarction (AMI) among 151 hemodialysis (HD) patients with diabetic nephropathy.
During the survey period, which included not only the period after HD introduction but also a one-year period previous to HD, 16 cases (10.6%) were complicated by AMI. In 9 of these cases, AMI occurred during the one year periods before and after the beginning of HD. AMI is the third leading cause of death (16.3%) in our population. Patients complicated by AMI had a high incidence of hypercholesterolemia and hypertension. In 76 patients with diabetic nephropathy who had been receiving HD for 3 years or more, fat metabolism improved annually, but the prevalence of hypertension did not decrease.
To improve the prognosis of diabetic nephropathy, it seems essential to correct hyperlipidemia and hypertension at an early stage and to assess and treat cardiovascular lesions at the point at which HD is introduced.

View full abstract

The utility of magnetic resonance imaging (MRI) in diagnosing hemosiderosis (H) was evaluated in patients on long-term hemodialysis. The study subjects were 19 patients with serum ferritin (Ft) ≥300μg/l and 4 patients with Ft<300μg/l served as controls, for a total of 23 patients on long-term hemodialysis receiving MRI examination. As a result, the intensity of the liver was diffusely reduced on T2 images in all 19 patients with Ft≥300μg/l The severity of hemosiderosis was divided into groups designated 0 to III according to the degree of siderosis as evaluated by MRI. In a patient of severity I, the T1 image was normal and the intensity was reduced only on the T2 image. In a patient of severity III, the intensity was reduced on both T1 and T2 images. On the other hand, both T1 and T2 images showed normal liver intensity in all 4 controls with Ft<300μg/l. Furthermore, the results of liver function tests including GOT and GPT were normal in all 23 patients. The MRI-assessed severity of H (0 to III) correlated positively with serum Ft and serum Fe. These results suggest that the T1 image is useful for evaluating the severity of H, the T2 image for early diagnosis and that MRI and Ft are useful for evaluating the therapeutic effects on hemosiderosis.

View full abstract

Influence of culture medium and glucose concentration on bacterial growth in Dianeal™ was studied. Various media were inoculated with Dianeal™ containing 10⁵, 10³ or 10¹cfu/ml of S. epidermidis, S. aureus, E. coli or P. aeruginosa. The media used included blood-agar, culture bottle and Uricult™. P.aeruginosa did not grow in the culture bottle medium below a concentration of 10³cfu/ml During a 24 hour incubation with these organisms in 1.5 or 2.5% Dianeal™, inhibition of bacterial growth was observed in S. epidermidis, S. aureus and P. aeruginosa. This result showed no changes according to glucose concentrations or osmotic values of Dianeal™. This tendency was obvious in cases in which the bacterial inoculum was small. P. aeruginosa showed the most remarkable tendency. However, the growth of E. coli was not inhibited when the inoculum was more than 10³cfu/ml Our results demonstrate that bacterial growth can be inhibited under special conditions such as a high osmolar environment. A study using peritoneal dialysis effluent should be condecuted in the near future.

View full abstract

We used MRI, a non-invasive imaging diagnostic technique, to diagnose complications in hemodialysis patients, and found that this technique was useful. The subjects were five hemodialysis patients with complications from the following diseases: metastatic tumor of the cervical vertebrae (Case 1 ); Grawitz tumor invading the pelvis (Case 2); arterial myxoma (Case 3); subcutaneous amyloid tumor (Case 4); liver abscess accompanied by acute renal failure (Case 5). For comparison, conventional imaging techniques such as CT, ultrasound, and standard X-rays were also used. The MRI equipment used was a MAGNETOM M5.
Cases 1 and 2: MRI was useful in diagnosing tumor metastasis into the bone because of its high resolving power, especially for distinguishing among tissues. Case 3: The valve ports and intracardiac structures could be clearly visualized by ECG gated MRI. For diagnosing diseases in the cardiovascular system, contrast media have been used in the past. However, since the excretion of the contrast media occurs via the kidney, using such drugs on hemodialysis patients has been considered undesirable, and thus the role of MRI as a diagnostic technique is likely to increase especially in the latter region in the future. Case 4: Although there have been no previous reports on the use of MRI for finding amyloid deposition associated with hemodialysis, a low-signal mass could be identified in the subcutaneous fat layer in both T1-weighted and T2-weighted images. The invasion of amyloid was also observed in a portion of the muscle layer. These findings agreed with those obtained at operation. Case 5: The liver abscess capsule was vosualized using MRI.
Various imaging techniques are currently used for the early diagnosis of complications in hemodialysis patients and for the assessment of therapeutic effects. The role of MRI in this workup has not yet been established, but it is highly possible that the scope of its indications will increase in the future.

View full abstract

In order to evaluate the adequacy of CAPD prescriptions, we used 41 stable CAPD cases to compare protein catabolic rate (pcr), KT/V, creatinine clearance (CCr) and serum albumin. The clinical assessment score, consisting of 8 symptom items and 4 laboratory items, was measured and classified into 3 degrees. There was a correlation between KT/V and pcr (r=0.55). CCr showed the best correlation with assessment score (CCr: r_s=0.52; KT/V: r_s=0.31; pcr: r_s=0.03; albumin: r_s=0.38). Likewise, among the 3 degrees of assessment score, a significant difference was observed only between CCr and albumin, but not between KT/V and pcr. Depending on clinical parameters such as peritonitis, complications and the past 6-month's hospitalization, assessment score and albumin indicated the most significant differences followed by CCr. KT/V and pcr showed no differences at all. Albumin, assessment score, CCr and KT/V are considered to be more useful than pcr as factors for evaluating the adequacy of CAPD prescriptions.

View full abstract

Eleven patients having symptoms of peripheral malcirculation on maintenance hemodialysis were treated with lipo PGE₁ which had been developed with the intention of selectively delivering the contained pharmacological agent, using lipid as a carrier, to the lesions of injured blood vessels. Diagnoses made on the basis of malcirculation symptoms were arteriosclerotic obstruction in 6 patients, steal syndrome in 4 patients and sore thumb syndrome in one patient. As a standard, 20 micrograms of PGE₁ was administered via a venous limb of the hemodialysis line in a slow one-shot manner at an end of regular hemodialysis. Observation periods ranged from 6 months to approximately 3 years.
Clinical symptoms improved in all patients. Warmness in the fingers and toes, amelioration of pain in the extremities including intermittent claudication and/or diminution in the size of ulcerative/necrotic lesions on the fingers and toes were obatined in arteriosclerotic patients. Warmness and pain relief were obtained in steal syndrome patients. Reduced swelling and pain relief were obtained in the sore thumb patient.
No serious side effects were observed.
We tentatively conclude that intravenous administration of PGE₁ may be an appropriate first choice in the treatment of peripheral malcirculation in maintenance hemodialysis patients.

View full abstract

In order to investigate the inhibitory effect of guanidine compounds (GC) on erythropoiesis, plasma levels of guanidine (G), methyl guanidine (MG) and guanidine succinic acid (GSA) were compared with colony forming uniterythroid counts corrected by plasma concentration of erythropoietin in hemodialysis patients with chronic renal failure (CRF).
Each GC was measured by HPEC and was found to be significantly elevated, e.g. G: 2.17±0.63nmol/ml, MG: 4.93±1.71nmol/ml and GSA: 14.48±4.26nmol/ml.
The CFU-E count was assayed by an in vitro culture method using fetal mouse liver cells, and the plasma concentration of EPO was determined by radioimmunoassay (RIA).
A corrected count of CFU-E was expressed in terms of CFU-E/log [EPO] and was significantly depressed in patients, 68.5±8.36/3×10³, as compared with the control value of 194.9±4.7/3×10³ (n=19).
Comparative analysis between plasma levels of GC and CFU-E/log [EPO] showed a weak negative correlation, which was not statistically significant.
Based on the present results, we could not confirm whether GC has a provable inhibitory effect on erythropoiesis in patients on maintenance hemodialysis.

View full abstract

Continuous arteriovenous hemofiltration (CAVH) has been employed in patients with multiple organ failure. The CAVH device is very simple and is able to filtrate over-hydrated fluid. CAVH methodology has been improved but an ideal blood access route has yet to be designed. We have introduced a one-way hemostasis valve and urokinase immobilized femoral vein catheter for blood access. A percutaneous Seldinger technique is used to insert a oneway valve into the femoral artery and a UK catheter into the femoral vein. We treated six acute renal failure patients including those with multiple organ failure. The duration of CAVH treatment varied between 52 hours and 411 hours, with a mean of 205 hours. The mean ultrafiltration rate was 578ml/h. Two patients survived and 4 patients died. The advantages of this access include quick introduction, simple device exchange, good blood flow and application to arterial pressure measurement.

View full abstract

This study was undertaken to investgate the efficacies of and problems associated with the use of LMWH as an anticoagulant during continuous hemofiltration (CHF) and continuous hemodiafiltration (CHDF). The incidences of bleeding complications with LMWH, heparin and nafamostat mesilate (NM) were 32%, 67% and 4%, respectively. The incidence of bleeding with LMWH was significantly lower than that with heparin (p<0.05) and was significantly higher than that with NM (p<0.005). The doses of LMWH did not differ significantly between the cases experiencing bleeding and those that did not. The combined method, using NM and LMWH, allowed for reduction of the dose of NM and extended the lifetime of the hemofilter, although the incidence of bleeding was still high (29%). These results indicate that the first choice of anticoagulant for continuous blood purification is NM and that the combined method might be effective in cases needing a large amount of NM and/or for whom the hemofilter and extracorporeal circuit must often be changed due to clotting problems. However, the lack of a bedside monitoring system to determine the optimal dose of LMWH during continuous blood purification remains a serious problem.

View full abstract

We have analyzed clinical conditions, severity, the relationship with multiple organ failure and prognosis in elderly patients with acute renal failure (ARF) requiring dialysis. This study was conducted on 46 patients over 65 years of age with ARE treated with dialysis in our hospital during the five year period between 1986 and 1990. Regarding the classification of causes leading to ARF, primary renal ARF was most frequent, 48%. Renal ARF secondary to prerenal factors accounted for 37%, and postrenal ARF for 15%. The etiology and precipitating factors of ARF, other than postrenal ARF, were infections, heart failure, dehydration, drugs and surgery. Prognoses are poor in these patients, as described below. The overall mortality rate was 59%. Complete or partial recovery from ARF occurred in 37% of the patients in this study. The mortality rate increased in ascending order with the numbers of damaged organs; kidney alone (15%), those with one another organ failure (50%), and those with more than two other organs (100%). The severity index was high, indicating the severity of ARF in the elderly; hence nurses could not leave the bedside during the hemodialysis treatment period in more than 90% of elderly ARF patients, as these patients required meticulous care. It is concluded that treatment of elderly ARF patients should be conducted with the utmost care in terms of psyco-somatic and surrounding factors.

View full abstract

We treated rhabdomyolysis (RML) by various methods of hemodialysis.
RML patients with underlying diseases are at particularly high risk, so immediate removal of myoglobin from the sera of such patients is essential. Recently, it has become possible to remove substances of high-molecular weight by hemofiltration using a high performance membrane (HPM). Applying the methods of hemofiltration (HF) and hemodiafiltration (HDF), we measured the myoglobin concentrations in PMMA membrane-filtered fluid at Q_B 200ml/min. The rate of myoglobin removal was 23.1%. HF using HPM also makes possible the removal of large amounts of myoglobin. We concluded that the combination of HF or HDF with HPM was effective in treating patients with RML.

View full abstract

We report here a patient who developed sudden hemolytic anemia, acute renal failure and hepatic failure following endoscopic sclerotherapy (EIS) for esophageal varix. The patient was a 60-year-old man with liver cirrhosis, type C. In April, 1990, he was admitted to our hospital to undergo EIS. It was performed three times using Aethoxysklerol (AS) He complained of chest pain and dorsal pain which commenced at the completion of the last EIS on May 8. In addition, he suffered from shaking chills. In the evening of the same day, hemolytic anemia occurred suddenly and the patient lapsed into a state of shock. Urine volume decreased and he became anuric at midnight on the same day. His condition was diagnosed as acute renal failure (BUN 110mg/dl, Cr 7mg/dl), and hemofiltration (HF) was started on May 10. Hepatic failure (GOT 3, 430U/l, GPT 1, 370U/l, PT 19%, hepatic coma degree V) also developed. Therefore, plasma exchange was started on May 12. Urine volume increased gradually as of May 20, HF was withdrawn on June 2 and his subsequent course was uneventful.
The hemolytic anemia seen in our patient was judged to be AS-induced innocent bystander type. It is said that this type develops abruptly after retreatment with a drug and tends to be complicated by acute renal failure. Many authors have reported acute renal failure as a complication of EIS which, however, is usually performed with ethanolamine oleate as the sclerosing agent. Therefore, our case treated with AS was cosidered to be a rare one.

View full abstract

A 26-year old man who had been undergoing hemodialysis for 4 years and 8 months was admitted to Sapporo City General Hospital for investigation of high fever, abdominal pain and melena. Endoscopic examinations on admission revealed multiple erosions, pseudopolyps, and mucosal friability with bleeding throughout the colon. A colon-biopsy specimen showed severe mucosal atrophy with chronic inflammatory infiltrate, goblet-cell depletion, and some crypt abscesses. These findings indicated chronic ulcerative colitis. Besides these findings, all biopsy specimens from the colon and stomach showed intramucosal and/or submucosal deposition of eosinophilic material that was congo-red positive. The deposits stained positively with anti-amyloid-A-protein antibody, and congo-red staining was completely abolished by prior treatment with potassium permanganate and diluted sulfuric acid, indicating that the deposits were amyloid of the AA type. The patient died of septic shock associated with acute necrotizing pancreatitis and peritonitis.
Autopsy revealed systemic deposition of amyloid A protein, and the colon showed a burn-out colitis with severe mucosal atrophy. There was absolutely no evidence of the disease leading to secondary amyloidosis other than ulcerative colitis.
In conclusion, this case was considered to have systemic amyloidosis secondary to chronic ulcerative colitis which ran without recognition and treatment up to the last admission to our hospital.

View full abstract

A 46-year-old man who had been undergoing hemodialysis for 10 years and had been diagnosed as having viral hepatitis type B when he was 39 years old was admitted to our hospital because of severe ascites.
We attempted many treatments including ECUM, water and salt restriction, rest and reinfusion of concentrated peritoneal fluid; however, none of the abovementioned procedures produced a favorable response. The patient was subsequently given 30mg of propranolol. After 10 weeks we detected a decrease in ascites and after 13 weeks were able to stop the reinfusion of concentrated peritoneal fluid. The patient made favorable clinical progress without side effects such as depression of liver function.
Propranolol is an effective treatment for ascites refractory to therapeutic interventions, such as reinfusion of concentrated peritoneal fluid, in hemodialysis patients whose condition is complicated by liver cirrhosis.

View full abstract

A 39-year-old man was admitted to our department with complaints of lumbago and gait disturbance. On physical examination, he was diagnosed as having stage III B testicular tumor. He received chemotherapy consisting of cis-platinum, bleomycin and vinblastine.
During the chemotherapy, he developed hemolytic uremic syndrome (HUS) with hemolytic anemia, thrombocytopenia, acute renal failure and uremic lung. He was treated with hemodialysis and artificial ventilation. HUS was cured and he was able to undergo further chemotherapy and salvage surgery for lung metastases. Unfortunately, he died of tumor recurrence and disseminated intravascular coagulation at 14 months after his initial admission.

View full abstract