The long-term effect of Elcatonin (synthetic eel calcitonin analog: ECT) in the treatment of renal osteodystroohy (ROD) was studied for 5 years. Patients with chronic renal failure undergoing hemodialysis, to whom 0.25-2.0μg/day of 1α-hydroxyvitamin D₃ (1α(OH)D₃) had been administered for more than one year, were randomly divided into two groups; an ECT group (n=23) and an age/sex matched control group (n=30). Patients in the ECT group were given a 40 IU infusion of ECT during each hemodialysis session. There were no significant differences between the two groups in blood biochemistries or in the dose of 1α(OH)D₃. Routine biochemical parameters, including immunoreactive parathyroid hormone (C-PTH), calcitonin (CT) and osteocalcin (BGP), and bone mineral content (BMC), which was assessed by means of microdensitometry, were evaluated every 6 months. The decrease in BMC was significantly smaller in the ECT group, and was more marked in patients at high risk, such as females, males aged more than 50 years and patients in the early stage of hemodialysis (less than 5 years). There were no marked changes in serum Ca, P or CT between the two groups. Serum alkaline phosphatase activity and levels of C-PTH and BGP were elevated in the control group, but there were no significant changes in these parameters in the ECT group. These results suggest that the long-term administration of elcatonin with 1α(OH)D₃ is safe and effective in preventing decreased BMC in patients undergoing hemodialysis.

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The effect of hepatitis B (HB) vaccine and accompanying factors was investigated in maintenance hemodialysis patients.
A study was conducted on 31 hemodialysis patients whose hepatitis B surface antigen (HBsAg), antibodies to HBsAg (anti-HBs) and antibodies to hepatitis B core antigen were negative. They were vaccinated 3 times (months 0, 1, 6) with 20μg HB vaccine and were divided into 3 groups according to anti-HBs levels (S/N;>10, 2-10, 2<). Phytohemagglutinin (PHA) skin test, subsets of peripheral blood lymphocytes, immunoglobulin levels, total protein (TP), hematocrit (Ht), c-parathyroid hormone (c-PTH) and age before HB vaccination were compared among groups.
The percentage (81.8%) of anti-HBs positives in the normal group (>205mm) on the PHA skin test was much higher than that (35.0%) of the abnormal group (<20.5mm). The levels of the PHA skin test in the good responders to HB vaccine were significantly higher than those of weak responders and non responders. Furthermore, the levels of the PHA skin test in the good responders decreased suddenly after vaccination. There were significant differences between the good responders and the weak responders, and between the weak responders and the non responders, in subsets of peripheral blood lymphocytes and immunoglobulins, but no significant differences between the good responders and the non responders. No significant differences were seen in TP, Ht, c-PTH and age.
These results suggest that the PHA skin test reflects the function of T-cells and is useful in predicting the effect of HB vaccination, and the quantity and frequency of vaccine should be increased for abnormal patients.

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We have observed the remarkable effectiveness of rHuEPO therapy in anemic patients with end-stage renal failure on hemodialysis. However, there certainly exists a small number of patients who respond poorly to rHuEPO therapy.
Most of the poor responders had iron deficiency, while increased hematopoiesis resulted in a drop in the serum ferritin level and % saturation of serum transferrin (%Tf) in most good responders. Deficiency and iron overload cannot be detected solely from the serum iron level and the changes in serum ferritin are a better indicator of these two clinical states. A serum ferritin level<50ng/ml suggests absolute iron deficiency which requires iron supplementation.
On the other hand, we also noted several patients with serum ferritin>50ng/ml (or even considerably higher) who had nevertheless responded poorly to rHuEPO. Most of them showed a %Tf<30%, suggesting functional iron deficiency.
We thus found that the serum ferritin and %Tf levels provide the most reliable guide for iron replacement therapy.
In conclusion, intravenous iron supplementation is necessary in patients with a serum ferritin level<100ng/ml and a %Tf<30%. Once a serum ferritin level>100ng/ml and a %Tf>40% are obtained, oral iron therapy may be considered based on the compliance and tolerance of each individual patient.

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Four types of dialyzers with high-performance membranes have been examined to evaluate their sieving coefficients (SC) and removal rates for low molecular weight proteins (MW; 11, 800-66, 000) such as β₂-microglobulin (β₂-MG), prolactin (PRL), α₁-microglobulin (α₁-MG), α₁-acid glycoprotein (α₁-AGP) and albumin (Alb) in four maintenance hemodialysis patients by cross-over methods. Studies involved CL-SS15W (SS), BK-1.6P (BK), FB-150U (FB) and AM-FP-15 (FP).
In SS, the SC of all solutes showed relatively higher values, although removal rates were lower than with the other types of dialyzers. This suggests that unequal amounts of dialysate flowed among fiber bundles in the dialyzer. In BK, the SC of β₂-MG, PRL and α₁-MG were low despite high removal rates, suggesting that the membrane absorbed these low molecular weight proteins, In FB, β₂-MG and PRL were removed efficiently, but other low molecular weight proteins showed lower removal rates and SC, suggesting that some low molecular weight proteins over 20, 000 to 30, 000 MW were not removed efficiently. In FP, SC was the highest but the removal rate was lower than the estimated removal rate based on SC. This suggests that this dialyzer did not maximize the characteristics of the high performance membrane in the same way as the SS.
In conclusion, these high-performance membrane dialyzers have good characteristic functions in removing low molecular weight proteins. A new method should be established to evaluate removal characteristics of low molecular weight proteins.

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In order to evaluate gastric motility in patients undergoing hemodialysis (HD), we measured gastric emptying (GE) in 25 HD patients (8 diabetics, 17 non-diabetics) by the radioisotope method. Autonomic nerve function and gut hormone levels were also examined.
^99mTc-labeled solid and liquid meals were used for the estimation of GE. Percentage of gastric retention (GR) of RI at 60 min after ingestion of a solid meal, and the half time (T1/2) of a labeled liquid meal were used as indicators marker of GE. GE was also measured in 6 normal controls. Autonomic nerve function was evaluated by the RR interval on an electrocardiogram (CV_R-R), and gut hormone, gastrin and motilin levels were measured before starting hemodialysis.
A significant positive relationship was observed between the value of GR of a solid meal and the T1/2 of a liquid meal. The values of GR of a solid meal in HD diabetics (72.0±11.3%) were significantly higher than those in HD non-diabetics (59.2±14.3%) and controls (50.1±9.9%). The mean values of T1/2 of a liquid meal were 103.1 min in HD non-diabetics, and 162.3 min in HD diabetics, which were significantly higher than the values in controls (mean 49.5 min). There was no significant relationship between GE and gut hormone level in either group. Although there was no relationship between GE and CV_R-R in HD non-diabetics, autonomic nerve dysfunction as evaluated by CV_R-R was observed in all HD diabetics.
It is suggested that in HD diabetics autonomic nerve dysfunction might result in disturbed GE of both solid and liquid meals. In HD non-diabetics, the pathogenesis of disturbed GE should be further investigated.

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Ischemic heart disease (IHD) has been recognized as an important risk factor in the mortality of chronic dialysis patients. We examined IHD with coronary angiography (CAG) and evaluated the results of percutaneous transluminal coronary angioplasty (PTCA) performed from July, 1987 to Noveber, 1991 in 25 dialysis patients with anginal pain and/or ischemic changes on electrocardiograms. They consisted of 20 men and 5 women with a mean age of 56.1 years (range: 40 to 74 years old), and 2 CAPD and 23 hemodialysis patients with a mean dialysis period of 4.5 years (range: 0 to 10 years) at the first CAG in Osaka National Hospital. The underlying causes of renal failure were chronic glomerulonephritis (7 cases/25 cases); diabetic nephropathy (10/25); polycystic kidney disease (2/25); nephrosclerosis (1/25); and unknown causes (5/25). Seventeen out of 25 patients (68%) had significant coronary-artery stenosis, while the rest (8/25, 32%) had no significant findings on CAG other than anginal pain. There appeared to be a tendency for calcified lesions in coronary arteries to become more prominent and more severe in proportion to the duration of the dialysis in non-diabetic patients. Stenotic lesions were found not to be located in any particular branch of a coronary artery. PTCA success was achieved in 18 of 21 (85.7%, patient success rate) and in 31 of 34 (91.2%, lesion success rate) stenotic sites attempted. All cases with anginal pain were relieved after successful PTCA. PTCA resulted in failure 3 times in 2 cases because the guiding wire could not pass through the stenotic lesions. Two mild dissections of stenotic lesions occurred as complications, whereas no other major complications occurred. Re-CAG in 4 cases demonstrated restenosis at dilated sites or new stenotic lesions (one case). Recurrent stenosis developed in a 5.4-month mean time interval (0 to 11 months).
We conclude that PTCA in dialysis patients is effective and as low-risk as in non-dialysis patients. Re-CAG will be recommended at appropriate time intervals to detect restenosis with or without aninal pain.

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Arteriovenous fistula blood flow was evaluated using an ultrasound duplex system composed of a doppler flowmeter and B-mode colour scanner, and the course of maturity and prognosis with the arteriovenous fistulae (radio-cephalic) were investigated in 15 patients. 1. In well matured fistulae (10 cases), the mean shunt flow volume of the radial artery increased rapidly 1 to 2 weeks after surgery, and reached 971ml/min 1 month after surgery, i.e. 10 times larger than the preoperative value. 2. In delayed (4 cases) and poorly (1 cases) matured fistulae, the average age of the patients was significantly higher (p<0.01), and the mean venous diameter following arteriovenous anastomosis was significantly smaller (p<0.05) than that in well matured fistulae. 3. Mean shunt flow volume of the radial artery 1 week after operation was significantly higher in well matured fistulae as compared with delayed or poorly matured fistulae (p<0.05). 4. The shunt flow volumes of the radial artery 1 month after operation were 560 to 1, 440ml/min in well matured fistulae and 220 to 480ml in fistulae with delayed maturation. Thus, shunt flow volumes exceeding 600ml are necessary for stable hemodialysis. 5. Back flows from distal portions of the radial artery to the shunts were recognized in 8 patients (53%) with this ultrasound duplex system and their average flow volume was 174ml/min (40 to 390).

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In order to monitor HD patients adhering to a phosphate restrictive diet and assure a sufficient protein intake, we devised an original chart based on the ratio of phosphate (P) to protein and considered the effectiveness of the dietary listutilize.
We studied 6 patients (2 males and 4 females, all between the ages of 29 and 66) on chronic dialysis whose mean serum P content was 6.0mg/dl before instruction. The amount of serum P, total serum protein, P intake and ratio of actual protein intake to suggested protein intake were measured and compared from day one, and 2 weeks, 6 weeks, 12 weeks and 16 weeks after instruction.
The mean value of serum P measurements before the start of instruction was 7.0±0.4mg/dl These values showed gradual and considerable decreases (p<0.01, p<0.05) to a mean of 5.6±0.6mg/dl at 12 weeks and 6.0±0.9mg/dl at 16 weeks. Total serum protein showed a significant increase (p<0.025) from the initial mean value of 5.7±0.4g/dl to 6.0±0.6g/dl and to 5.9±0.5g/dl 12 and 16 weeks after instruction, respectively.
Initial P intake was reduced from 663±72mg to 572±66mg at 12 weeks and to 591±107mg at 16 weeks. The initial ratio of actual protein intake showed a tendency to approach the prescribed protein intake from 83.7±17.2% to 84.0±17.6% at 12 weeks and to 88.1±16.3% at 16 weeks.
From these results, our original chart of the phosphate to protein ratio seems to be an effective method of instruction for patients on phosphate restrictive diets.

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In order to prevent uremic complications, rehabilitate earlier and reduce the frequency of visits to the hospital, we have attempted once-a-week maintenance hemodialysis for aged uremic patients. The subjects were 11 aged uremic patients (age 68-82, 74±4) without heart failure, whose serum creatinine concentrations were below 13.0mg/dl (8.2-12.3, 9.9±1.3mg/dl). All 11 patients were in good condition with once-a-week maintenance hemodialysis for 1.5-13 months (6.6±4.3) without medical problems. The frequency of dialysis was increased to two 4-hour treatments per week because of elevated BUN or creatinine (6 of 11) and increased interdialytic body weight gain (4 of 11). Once-a-week maintenance hemodialysis is a useful therapy for aged uremic patients.

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For chronic hemodialysis patients, obstipation is a serious problem which necessitates habitual cathartics. Lesions of the anus caused by obstipation seem to be a frequent complication of many chronic hemodialysis patients, but no reports have thus for been published on anal lesions. Thus, we examined our nine cases operated on for anal lesions. We had 6 male cases with internal hemorrhoids and one case of fistula ani. Over two years there were 542 operations for hemorrhoids in non-hemodialysis cases, of which 63% were internal hemorrhoids, 23% were fistula ani and 14% were fissure ani. In spite of anemia and poor immunological condition, there were few fistula ani and fissure ani among hemodialysis cases and we can therefore speculate as to whether this would be expected. Hemodialysis patients who needed anal operations reclined the surgery fairly soon after the initiation of hemodialysis therapy and it was apparent that they had been suffering from the same problems for a long time prior to therapy, which obviously aggravated the anal lesions. But, unexpectedly, if no and lesions were present on introduction of hemodialysis, no matter how resistant the constipation was, they seemed not to be predisposed to developing anal lesions.

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In general, diabetic dialysis patients (DM-HD) infrequently develop secondary hyperparathyroidism (2°HPT). In order to clarify parathyroid function in DM-HD patients, we investigated several baseline parameters of Ca metabolism in 30 DM and 30 non-DM patients and observed the PTH release induced by acute hypocalcemia during Ca-free HD in 5 DM and 6 non-DM-HD groups.
In studying the baseline level, the DM-HD group consisted of 19 males and 11 females, mean age 59.8 years, with dialysis periods of 12.6 months on average. The non-DM group consisted of 16 males and 14 females, mean age 54.6 years and with dialysis periods of 15.7 months. The two groups showed similar levels of Ca, Pi and Al-P, but C-PTH levels were lower in the DM-HD (1.7±1.5ng/ml) in comparison with the non-DM (3.6±2.3ng/ml). There were no significant correlations among PTH, age and dialysis period, but there were significant correlations between PTH and serum P levels in the DM-HD group (r=0.51, p<0.05) and between PTH and serum Ca in the non-DM-HD group (r=-0.59, p<0.05).
In the Ca-free HD study, 2 groups showed similar decreases in serum Ca and similar increments in Intact-PTH (ΔIntact-PTH) from baseline. However, because of lower PTH levels, the area under the curve in the DM-HD group was smaller than in the non-DM-HD group.
In conclusion, we confirmed lower baseline PTH levels in the DM-HD, but the PTH response to hypocalcemic stimulation is well maintained, and we speculate that basal PTH secretion may be suppressed in the diabetic state through a cell membrane abnormality.

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This study was performed to evaluate the effect of dietary treatment in hemodialysis patients. The subjects were 17 patients on standard, regular hemodialysis, who were principally not administered phosphate binders. A free diet before admission and a low-protein, high-energy, low-phosphate diet (protein 40g/day, energy 2, 200 kcal/day, NaCl 3g/day, phosphorus 530mg/day) for 2 weeks after admission were compared. The parameters were blood urea nitrogen (BUN), serum phosphorus (P), serum calcium (Ca), Ca×P level and serum protein. The blood chemical values decreased significantly (p<0.01) as follows; BUN from 75±17mg/dl to 57±15mg/dl, serum P from 7.5±2.1mg/dl to 4.5±1.3mg/dl, Ca×P level from 69±22 to 44±12. The serum Ca was significantly (p<0.01) elevated after dietary treatment. Serum protein was not significantly changed. From these results, low-protein, high-energy, low-phosphate dietary treatment without phosphate binders was proved to be effective in controlling not only BUN level, but also serum P level in hemodialysis patients.

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Exertional heat stroke developed in a 29-year-old man who ran a long distance race (10 kilometers) in cold weather. Multiple organ failure including acute renal failure, hepatic failure, pancreatitis and disseminated intravascular coagulation occurred on the fifth hospital day. Hemodialysis and plasmapheresis with the administration of nafamostat mesilate as well as AT-III resulted in improvement of multiple organ failure. The renal biopsy specimen obtained during the recovery stage revealed residual evidence of acute tubular necrosis. This case indicates the usefulness of hemodialysis and plasmapheresis as a treatment for multiple organ failure induced by exertion al heat stroke.

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This report centers on the management of hemodialysis for a child, dialyzed as of 3 months after birth, using a dual lumen catheter (Permcath^®) for 4 years and 1 month.
The child is male born in June 1981, and he had a dialysis history of 9 years and 6 months as of March 1991.
The management of the catheter (Permcath^®) consisted of the following: 1. unification of measures for prophylaxis against infection and blockage, 2. prevention of friction and movement of the catheter by (1) making a chest belt, (2) specially designing a schoolbag, and (3) applying stripped T gauze, 3. orientation for the patient and his parents, and 4. emphasizing close communication with his school. As a result of the above measures, the Permcath^® could be used for 4 years and 1 month from the time when the patient was 5 years and 5 months old until he was 9 years and 9 months old, without clinical problems.
Prevention of catheter replacement is possible by replenishing heparin on non-dialysis days. When the insertion area was infected, it was treated by increasing the number of sterilizations, by administering antibiotics, and securing the Permcath^®.
The catheter was cracked and had to be removed. The Permcath^® ensured the initiation of dialysis for the child without pain caused by shunt piercing, decreased restrictions on body movement and allowed him to participate fully in study and play. The boy could spend the period from early childhood to the early years of elementary school in a very stable condition mentally. He was able to attend nursery school and go to a local elementary school, and the overall QOL of this child was enhanced.

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A 57-year-old woman with chronic renal failure and diabetes was admitted because of persistent nasal bleeding and anemia. Laboratory findings on admission showed pancytopenia and end stage renal failure (WBC 2, 800/mm³, Ht 20.8%, platelets 2.2×10⁴/mm³, BUN 77.1mg/dl, Cr 6.7mg/dl and 24 hrCcr 6.1ml/min). Aplastic anemia was diagnosed on the basis of the plasma iron disappearance rate, bone marrow scintigram, myelogram and past history. Hemodialysis therapy and intravenous injection of 6, 000U recombinant human erythropoietin (rHuEPO) three times a week was started. Reticulocyte counts temporarily increased three days later, but decreased again, and pancytopenia did not improve. Therefore, rHuEPO doses were increased to 12, 000U one time after 2 weeks of treatment. Then, 2-3 weeks later, WBC, Ht and platelets rose significantly. Currently, she receives rHuEPO at a dose of 1, 500U twice a week and her in laboratory findings, scintigram and myelogram are improving. We have reported an interesting case in which high-dose rHuEPO was effective in increasing WBC and platelets as well as Ht.

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In June of 1981, we initiated treatment by hemodialysis and peritoneal dialysis. To date, five elderly patients (4 males and 1 female) have accepted CAPD. Their primary diseases were chronic glomerulonephritis (2), urinary stone (1), heart failure (1) and chronic rheumatoid arthritis (1). The average age was 77.4 years (range, from 72 to 89), and the mean period of CAPD maintenance was 17.4 months (range, from 2.5 to 55). Three patients were able to return home, but the other two were obliged to stay in the hospital. In all cases, dehydration combined with excessive hypotension characteristically occurred soon after induction and continued without improvement. Thereafter, they became inactive and gradually lapsed into dementia. Ultimately 3 patients necessitated interrution of CAPD and initiation of hemodialysis. Two of these died because of digestive tract hemorrhage and another died of inadequate nutrition. The remaining 2 also died of inadequate. nutrition but without returning to hemodialysis.
Accordingly, we have described the clinical course of the three patients who were able to return home, and have elaborated on the metabolic balance of water and electrolytes from a geriatric point of view, and problems with CAPD in the elderly population.

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A number of investigations have provided evidence of the adverse effects of hyperhpidemia on the progression of renal injury. A combined therapy utilizing low-density lipoprotein apheresis (LDL-A) and pravastatin was applied to 15-year-old boy with drug-resistant nephrotic syndrome due to focal segmental glomerulosclerosis (FGS), presenting with severe hyperlipidemia. LDL-A was carried out twice a week for 3 weeks using an LDL sorbent column containing dextran sulfate cellulose beads (Liposorba LA-15). A total of 3, 000ml (60ml/kg) of the patient's plasma was treated with each LDL-A. After the introduction of this therapy, renal function improved (serum creatinine; 3.4→0.9mg/dl, creatinine clearance; 24.3→76.8ml/min/1.73m²) concomitantly with a reduction in hypercholesterolemia (approximately 700→250mg/dl), whereas urinary protein excretion was not significantly improved (approximately 25→15g/day). Decreased urinary thromboxane B₂ excretion was also observed (239.9→128.6ng/day).
In conclusion, combined therapy using LDL-A and pravastatin seems to be effective in improving renal function in patients with drug-resistant nephrotic syndrome due to FGS. As one possible mechanism for the effectiveness of this combined therapy, we speculate that there is an improvement in hyperlipidemia resulting in suppression of the intrarenal thromboxane A₂ overproduction seen in nephrotic hyperlipidemia.

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A 74-year-old man was admitted because of anuria after suffering from pneumonia. Hemodialysis was initiated because of progressive deterioration of renal function. He was diagnosed as having multiple myeloma after examination of bone marrow and serum and urinary immunoelectrophoresis. Renal biopsy findings were compatible with myeloma kidney with multiple tubular casts. Chemotherapy with prednisolone and melphalan improved renal function and hemodialysis was successively withdrawn. Active treatments such as hemodialysis, plasmapheresis and chemotherapy for multiple myeloma may be beneficial in cases associated with acute renal failure.

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