It is now possible for children to undergo acute hemopurification for the treatment of acute renal failure (ARF) and acute hepatic failure (AHF) because of progress in critical care medicine, intensive care and hemopurification. We performed acute hemopurification in 15 children. Twelve children underwent acute hemopurification for ARF and 7 survived. Three children were treated by this means because of AHF but all of them died.
Because blood vessels in children are small, the supply of vessels adequate for hemopurification is limited. This study was undertaken to investigate arterial and venous access in children, especially low body weight children, for acute hemopurification.
Peritoneal dialysis only was performed in 4 children whose body weights were from 4.4 to 18 kilograms (kg). Hemodialysis was performed in 6 children whose body weights were from 14 to 64kg, Access for the arterial line and the central venous catheter of 16G size was available for plasma exchange, but not for hemodialysis because of insufficient blood flow which was lower than 3ml/kg/min.
Under these circumstances, an FDL catheter which was recently developed and ranges from 7 to 10 Fr. in the femoral vein, would be the most acceptable access for acute hemopurification in children. However, another access such as an external shunt must also be selected if complications such as bleeding tendency, sepsis and stenosis of the femoral vein develop.

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In order to evaluate changes in peritoneal membrane functions during the period of continuous ambulatory peritoneal dialysis (CAPD) and the influences of peritonitis, we studied peritoneal clearances and dialysate/plasmaratios of creatinine and ultrafiltration volume in 30 long-term CAPD patients (mean duration of CAPD: 36 months). There were no yearly decreases in peritoneal functions even in the peritonitis group (n=18). But clearances and ultrafiltration volume significantly decreased in patients who had suffered from peritonitis for an extended period (over 7 days, n=8), as compared with those in the shorter duration group (under 7 days, n=10).
The results of this study suggest that peritoneal functions remain unchanged after long-term CAPD and that prolongation of peritonitis might cause the observed decreases in peritoneal functions. We conclude that it is important to detect and aggressively treat peritonitis as soon as possible in order to preserve good peritoneal function.

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Eleven patients with chronic renal failure undergoing CAPD (2 females and 9 males, mean age 42.2 years) were treated for renal anemia with self-administered subcutaneous (SC) erythropoietin (EPO) injections.
At the start of treatment, a 3, 000 U dose of EPO (46.2-75.0 U/kg) was administered three times per week (total 9, 000 U per week) by SC self-administration. After 2 months, the dose was adjusted so that each patient's hematocrit (Ht) was maintained at 30±2%.
Ht was significantly increased from a pretherapeutic value of 19.4±4.0% to 21.3±4.1.% at week 2 of therapy, 25.2±3.8% at week 4, and 28.3±1.9% at week 8.
All patients showed significant improvement in anemia following 3 months of therapy; improvement continued for up to 2 years. No patients were observed to become refractory to EPO therapy. With the exception of one patient, there was no depression in serum ferritin level so marked as to require iron supplementation.
As anemia improved, subjective symptoms, such as fatigability, anorexia, and shortness of breath improved markedly, with a concomitant increase in exercise tolerance No patient exhibited locallized side effects from injection, such as erythema, induration, or evidence of infection. No changes were observed in serum UN, Cr, electrolytes, liver enzymes, eosinophils, and platelet count. All patients tested were negative for anti-EPO antibody with treatment of 2 years duration or more.
One patient required a higher dose of antihypertensive medication to control hypertension and rejected further EPO therapy. Another patient developed hypertensive encephalopathy after discontinuing antihypertensive medication, and EPO therapy was discontinued. All other patients showed no changes in blood pressure.
From these results, SC EPO self-injection is considered to be the most efficacious means of treating renal anemia in patients with CRF on CAPD. However, blood pressure should be carefully monitored to guard against the hypertension which may develop during EPO therapy.

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When emergent blood access is needed in patients without arteriovenous shunt, the double lumen catherization (Femoral vein catherization: FVC) method is usually applied. However, this method is sometimes accompanied by severe complications, e.g. hematoma and infection. Therefore, instead of using the FVC method, we tried to puncture the femoral vein repeatedly in cases in which blood access was needed (Femoral vein puncture (FVP) method). Blood was returned to the forearm vein in this method. In the present study, we compared the risks and efficacies of the two methods in patients in need of emergent blood access. Fifty patients who needed emergent blood access were included in the present study. They were in relatively good condition and alert enough to remain quiet during the hemodialysis treatment. The FVC and FVP methods were used in 30 and 20 patients, respectively. The backgrounds of the two groups such as their ages, and predialysis levels of serum creatinine, blood urea nitrogen, and potassium were comparable. Blood flow rates obtained by these methods are similar (FVC 184±3.1 vs FVP 189±6.0ml/min). However, the clearance efficiency of creatinine was significantly higher in the FVP group (FVC 56.2±1.5 vs FVP 51.1±1.9%: p<0.05) probably due to the absence of partial shunt with the FVP method. It is of note that there was no complication directly linked to blood access with the FVP method while 33.3% of the patients receiving FVC (10/30) had severe complications requiring medical treatment (p<0.05: X²). Moreover, during the treatment period, the catheter had to be changed in 40% of the FVC group patients due to difficulties in obtaining proper blood flow. Based on these data, we conclude that the FVP method is safer and less expensive (a single FVP needle is much cheaper than that used for FVC) than the FVC method. The FVP method might be useful in cases requiring emergent blood access in the absence of an arteriovenous shunt.

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We conducted a study of cholecystolithiasis in 776 dialysis patients who underwent ultrasonographic examination at Kojin-kai Hospital from March 1983 to December 1990. Cholecystolithiasis was found in 160 out of 776 patients (20.6%), and the incidence tended to increase with increasing age. However, there was no statistical difference between men and women. Among underlying diseases, diabetic nephropathy accounted for as much as 31.3% of all patients with cholecystolithiasis. It was also detected in 9 out of 16 dialysis patients with liver cirrhosis (56.3%). Cholecystectomy was performed in 5 men and 10 women. Gallstones were found in 12 and bilirubin gallstones in 3. Ultrasonography was useful for clinical observations, because cholecystitis recurred very frequently in 11 of 15 patients preoperatively. The rate of association of carcinoma of the gallbladder in all hemodialysis patients at our hospital was about 10 times higher than in non-hemodialysis patients (0.26%, 2 out of 776 patients). The rate of association of carcinoma of the gallbladder with cholecystolithiasis was also 1.3% (2 out of 160 patients). As both of the patients were female and in their 70's, care should be taken with regard to follow-up periods in aged patients with cholecystolithiasis.

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Seventy-two hemodialysis patients with chronic renal failure were studied with regards to the relationship between obstruction of the autogenous internal A-V fistula and the plasma level of von Willebrand factor (vWF). vWF was measured as the level of factor VIII-related antigen, using enzyme-linked immunosorbent assay.
vWF was elevated in the hemodialysis patients, as compared with the normal range (60-150%), to 165±51% (mean±SD). Nine non-diabetic patients who had had patent A-V fistulae for more than 10 years were included, showing a vWF range of 125-198%. In addition, 8 non-diabetic patients whose A-V fistulae had become stenotic or obstructed within 3 years were studied. Out of the 8 patients with these stenotic or obstructed A-V fistulae, 5 showed markedly elevated vWF levels of over 200%, and 2 showed vWF levels under 125%, contrasting with the range of the 10-year-patent patients (p<0.01).
The present data suggest that an elevated vWF level is related to the etiology of obstructed A-V fistula. In patients with markedly elevated vWF, it is suggested that endothelial cells may be in a state of perturbation or injury, which leads to intimal venous hyperplasia. On the other hand, in the few cases with comparatively low vWF levels, it is possible that endothelial cell function may be insufficient for the development of an arterialized vein.

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The accumulation of 3-carboxy-4-rrmethyl-5-propyl-2-furanpropionic acid (CMPF) and indoxyl sulfate, as albumin-bound uremic toxins, occurs in the serum of uremic patients and these compounds cannot be efficiently removed by hemodialysis. To determine the pathogenic roles of CMPF and indoxyl sulfate in uremic patients, their cellular toxicities, as manifested by their effects on mitochondrial respiration, were studied.
CMPF showed dose-dependent inhibition of NADH-linked mitochondrial state 3 respiration. The inhibition was also observed in the presence of serum albumin, and even at a concentration of 50μg/ml, which is comparable to the serum level of CMPF in uremic patients on regular hemodialysis treatment. Indoxyl sulfate, however, showed much weaker inhibition of mitochondrial respiration as compared to CMPF.
These results suggest that CMPF is toxic to cells due to inhibition of energy (ATP) synthesis secondary to impaired mitochondrial respiration.

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In order to evaluate dialysis and nursing problems of aged patients with diabetic nephropathy, two groups of patients over 65 years of age were compared.
Group A consisted of 5 diabetic patients and Group B of 5 non-diabetic patients. The mean age of Group A was 69.2 years and that of Group B 71.0 years old. The clinical data at the beginning of hemodialysis were not different between two groups, but many cases in Group A began hemodialysis as a result of overhydration. Since hypotension of more than 40mmHg of systolic blood pressure during hemodialysis was frequently found in Group A, intensive nursing with ECG monitoring, prevention of hypotension, control of blood sugar, early detection of symptoms, and control of water intake was recommended in this group.
Aged patients with diabetic nephropathy have many complications and show deterioration of physical functions. Therefore, the care and support of family members and neighbors are often needed with advancing age.
To maintain or improve the quality of life in aged patients, patients and their families should be educated effectively to reduce mental stress and physical problems.

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Various complications have been reported to occur with long-term CAPD. One of these problems is a decrease in the efficiency of dialysis through the peritoneum associated with protracted treatment. The dialyzing efficiency in CAPD can be assessed by two means: the ultrafiltrability of solutes and the dehydration activity. We evaluated ultrafiltrability of solutes from the peritoneal clearance and dehydration activity from the peritoneal function index (PFI), in six patients who had been maintained on CAPD for at least 60 months. In terms of peritoneal clearance, UN, creatinine and phosphorus showed a slight tendency toward elevation in D/P, while these values were roughly constant in V/T. Thus the clearance, like D/P, tended to rise. PFI decreased year by year, suggesting a decrease in the dehydration activity. The above findings were consistent with the hospital record which indicated that, as dehydratin activity diminished over the course of 60 months or more of treatment, a higher-concentration of dialysate became necessary more and more frequently to ensure a certain level of UF. We think it possible to predict the time when UF ceases by observing the decrease in PFI.

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We report a hemodialysis (HD) patient, in whom interferon α was administered as an effective therapy for posttransfusion chronic hepatitis C. Liver dysfunction (GPT: -100mU/ml, GOT: -50mU/ml) in a 38-year-old man, who had been transfused 50 units of blood during six years of HD therapy, was diagnosed as chronic hepatitis C because anti-Hepatitis C Virus (HCV) antibody test using C100-3 antigen (Chiron Corp.) was positive. Liver biopsy showed lymphocytic infiltration in the portal area, which was compatible with chronic persistent hepatitis. The patient received a bolus injection of interferon α (3 million units, i.m.) daily for 2 weeks and, subsequently, three times per week for the next six months. Serum GPT level began to decrease within the first month of treatment and the serum levels of other hepatobiliary enzymes normalized over the following six months. Disappearance of the lymphocytic infiltrations was then confirmed with a second liver biopsy. Alopecia and granulocytopenia were seen as adverse effects of interferon α, but neither of these was serious or irreversible. In the seventh month of treatment, interferon α remained detectable in the serum even two days after injection, and a higher peak concentration as well as delayed disappearance of interferon α after injection, as compared to healthy controls, were noted. Also, interferon α was not detected in filtrate obtained by extracorporeal ultrafiltration method with a PAN membrane dialyzer. These data suggest that interferon can accumulate in HD patients if the standard dose is applied for a long period of time.
In conclusion, although adequate doses for HD patients and long-term prognosis remain to be clarified, interferon α is considered a therapy of choice for chronic hepatitis C.

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We report here a patient who developed rapidly progressive renal failure associated with essential IgM-κ monoclonal cryoglobulinemia. A 75-year-old woman was admitted to our hospital because of generalized edema and progressive renal failure. Physical examination revealed ascites and edema of the lower extremities. Laboratory data on admission were as follows: urinary protein 1.8g/day, Ht 31.6%, total protein 5.4g/dl (albumin 63.4%), BUN 89.7mg/dl, Cr 3.6mg/dl. In the serum, cryoglobulin was found with a cryocrite of 2% and immunoelectrophoresis demonstrated IgM-κ monoclonal protein.
Examination of bone marrow disclosed no findings suggestive of any lymphoproliferative disorder. A diagnosis of rapidly progressive glomerulonephritis associated with essential IgM-κ monoclonal cryoglobulinemia was made. She was treated with prednisolone and cyclophosphamide and thereafter underwent cryofiltration for the purpose of cryoglobulin removal. Generalized edema and renal function improved following cryofiltration therapy. The patient's response to therapy suggests that cryofiltration is a useful procedure for treatment of rapidly progressive glomerulonephritis associated with cryoglobulinemia.

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