To study the clinical significance and mechanism of complement changes in patients undergoing longterm hemodialysis for chronic glomerulonephritis, the classical pathway (CP) of the complement system was examined in 28 patients, i.e., the C1r-C1s-C1 Inhibitor complex (C1r-In), a strict indicator of complement activation by CP, was measured by ELISA using microplates. CH50, C3, C4 and the C3 breakdown product C3d were also examined.
Simultaneous measurment of circulating immune complexes (CIC) was also carried out to detect complement activating factor.
The results were as follows; 1. C1r-In and CIC levels in chronic hemodialysis (HD) patients were significantly higher than in normal subjects. A significant correlation between C1r-In and CIC (r=0.7157, p<0.001) was observed. 2. C1r-In levels were significant correlated with CH50 (r=-0.4396, p<0.05) and C3d/C3 (r=0.3861, p<0.05). 3. The CIC values were negatively correlated with C3 (r=-0.4048, p<0.05), and C4 (r=-0.3789, p<0.05). In addition, a positive correlation between CIC and C3d/C3 (r=0.4844, p<0.01) was seen. These findings suggested that the CP of the complement system, in which CIC is involved, was activated in HD patients with glomerulonephritis. These facts seem to be very important in considering clinical symptoms and complications in HD patients.

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The peritoneum tends to be thick and adherent in CAPD patients with a history of abdominal surgery or peritonitis. We attempted to institute CAPD in six patients with a history of abdominal surgery, and succeeded in five, but failed in one who had a history of severe peritonitis due to Pseudomonas aeruginosa.
We measured peritoneal thickness by ultrasonography (US) in 17 CAPD patients, five with a history of abdominal surgery (Group S), six with a history of peritonitis (Group P) and six with a history of neither (Group N). We also examined peritoneal adhesions using both US and radiographic computerized tomography (CT). Peritoneal thickness was 4.8±1.9mm in Group S, 2.6±0.8mm in Group P and 2.9±1.0mm in Group N. US yielded positive rates for peritoneal adhesions of 40.0%, 40.0% and 42.9%, respectively, whereas the rates were 25.0%, 0%, and 40.0% on the basis of CT. No marked tendency foward peritoneal adhesion was seen on either US or CT images.

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To evaluate the eflects of improvement in renal anemia on cerebral blood flow, six patients on initial hemodialysis therapy were studied before and after improvement of their anemia using recombinant human erythropoietin (rHuEPO). In five of the six patients the hematocrit increased more than 28%, while in one patient it remained under 23%.
Cerebral blood flow was measured by single photon emission computer tomography using ¹³¹I-IMP. The results were as follows. Anterion cerebral blood flow decreased from 84.61±21.91 (ml/100g/min) to 75.74±20.28, posterior cerebral blood flow from 98.42±24.52 to 86.34±23.69 (p<0.05), and whole cerebral blood flow from 91.53±24.53 to 81.05±21.55 (p<0.05).
These results indicated that cerebral blood flow increased by anemia can be improved by the use of rHuEPO.

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In order to study morphological changes in the peritoneum accompanying CAPD therapy, the mesenterium of 30 patients on CAPD (CAPD duration; 1-86mo) was examined by ultrasonography. Morphological evaluations of the peritoneum were expressed as thickness of the mesenterium at the midpoint between its attachment to the small intestine and it origin. Long-term CAPD (more than 5 years) and the use of high concentration dialysates affected the thickness of the mesenterium. There was no significant correlation between body mass index (BMI) and thickness of the mesenterium. A significant negative correlation was found between the ultrafiltration function and thickness of the mesenterium.
These findings suggest that examination of the mesenterium may be useful in understanding the pathophysiology of the peritoneum in CAPD patients and that ultrasonography provides a simple method of examining the mesenterium.

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The long-term effect of parathyroidectomy (PTX) on renal osteodystrophy (ROD) in hemodialysis (HD) patients has not been extensively studied so far. To examine this effect, we performed a cross-sectional study. Biochemical parameters of bone and bone mineral content, were measured in HD patients, who were divided into control (18 patients), secondary hyperparathyroidism (14 patients, 2°HPT), and PTX (8 patients, 45-56 months after PTX and autotransplantation of parathyroid glands) groups. Serum levels of C-PTH, intact-PTH, and osteocalcin were similar in the control and PTX groups, but these levels were significantly higher in the 2°HPT group than in the other two groups. The bone mineral content was measured by dual-energy X-ray bone absorptiometry. The ratio of total bone mass to lean body mass was significantly lower in the 2°HPT group than in the control group. Most other parameters, i.e. bone mineral content of total body, head, spine, trunk, arms, and legs, were lower in the 2°HPT group than in the control group, although the differences were not statistically significant. In contrast, the values of all parameters related to bone mineral content were similar in the PTX and 2°HPT groups. Our results suggest that PTX improves the biochemical parameters of bone, but may not necessarily restore the bone mineral content after 45-56 months. Further longitudinal study is necessary to confirm this conclusion.

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Recently we have reduced the dosage of 1α D₃ for hypercalcemia not only by changing the calcium concentration of dialysates ([D]_Ca) but also by using CaCO₃. In order to clarify the optimum dosage of 1αD₃ for preventing 2°HPT, we performed a retrospective study as follows. Fifty maintenance hemodialysis patients were divided into several groups according to the conditions of administration of CaCO₃ and 1α D₃, and to [D]_ca. In each group, the changes in calcium and bone metabolites were examined. The results showed that administration of 0.75-1.0μg/day of 1α D₃ seemed to prevent an increase in serum C-PTH at normal serum Ca levels (mean 9.6mg/dl), but administration of a lower dosage (<0.5μg/day) was associated with a higher serum Ca level (mean 10.0mg/dl), and moreover, the serum P level tended to increase at the same time. Accordingly there is a danger of ectopic calcification. Therefore, we recommend the administration of 0.75-1.0μg/day 1α D₃ as the optimum dosage for preventing 2°HPT.

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Ursodeoxycholic acid (UDCA), a metabolite of cholic acid, modifies bile juice and is believed to increase absorption of lipids and lipid-soluble vitamins. A number of reports have shown increased 25-hydroxyvitamin D [25(OH)D] levels after administration of UDCA in healthy subjects and patients who have undergone resection of the intestine, suggesting that absorption of vitamin D might be stimulated. In this study, we observed the effect of UDCA on the levels of serum vitamin D metabolites in 16 patients on maintenance hemodialysis and being treated with 1.0μg/day of 1α-hydroxyvitamin D₃ [1α(OH)D₃]. UDCA was administered orally (10mg/kg/day) to 10 patients and placebo was administered in the same dose to 6 patients. Fasting blood samples were drawn for measurements of 25(OH)D and 1, 25-dihydroxyvitamin D [1, 25(OH)₂D] before and one month after administration of UDCA. UDCA increased the level of 25(OH)D but decreased the level of 1, 25(OH)₂D. 1α(OH)D₃ is a pro-drug for 1, 25(OH)₂D because it is metabolized and synthesized into 1, 25(OH)₂D₃ by the liver. Therefore, this drug is suitable for patients with impaired 1α-hydroxylase activity, such as those with chronic renal failure (CRF) or hypoparathyroidism. It has been reported that UDCA may increase the plasma level of 25(OH)D in patients with malabsorption syndrome. This increase would be beneficial provided the patients have intact renal function and can therefore convert 25(OH)D to active 1, 25(OH)₂D. It we conclude that, although UDCA is useful and effective in normal renal function, its use should re-evaluated in patients with CRF.

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To evaluate the efficacy and side effects of nicardipine hydrochloride in the treatment of severe hypertension during hemodialysis, nicardipine hydrochloride was administered to six patients with hypertension that could not be controlled by conventional antihypertensive drugs such as sublingually administered nifedipine.
Systemic blood pressure significantly decreased from 216.2±17.2mmHg to 152.5±26.2mmHg at one hour after the administration was started (p<0.05). During dialysis, adequately controlled arterial pressure persisted without serious complications. There were no side effects except for a headache in one patient.
We conclude that continuous intravenuous administration of nicardipine hydrochloride may be useful in treating otherwise unresponsive hypertension during hemodialysis.

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We estimated the concentration of serum amyloid P-component (SAP) in patients on maintenance dialysis (HD). The following results were obtained. 1. SAP levels in HD patients (n=70) were higher than those in healthy subjects (n=69). 2. SAP levels were statistically correlated with α₁-AT, C4 and CH50 levels. 3. SAP levels fell during hemodialysis, possibly due to absorption by the dialysis membrane.

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The authors have devised a new treatment strategy using continuous ambulatory hemofiltration (CAHF) between short duration hemodialysis (short HD). For CAHF, a small wearable hemofilter (0.1m²) was developed using a membrane permeable to low molecular weight proteins. During short HD, no body water is removed, but saline equivalent to 3% body weight is administered at a constant rate. During CAHF, one liter of replacement fluid is administered intravenously after each meal in order to increase the replacement volume. The switch from conventional strategy to the new strategy has resulted in far more stable blood pressure during short HD, a decrease in time-averaged body weight, and a decrease in time-averaged blood urea nitrogen levels and plasma β₂-microglobulin levels.

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The ultrafiltration in CAPD was reduced soon after intravenous hydrocortisone administration for left sudden deafness in a 53-year-old male with diabetic nephropathy. The effect lasted about two weeks, but was easily reversed by dialysis with more hyperosmolar dialysates. To elucidate the mechanism of this, changes in ultrafiltration volume and clearance of electrolytes and solutes were examined with administration of 250mg hydrocortisone. The ultrafiltration volume was reduced immediately after the administration, and the clearance of Na and Cl decreased. After hydrocortisone administration, the absorption of Na and Cl from the dialysate across the peritoneal membrane into the blood was accompanied with free water, which might have resulted in the reduced ultrafiltration.
The precise mechanism by which this phenomenon occurred is unclear. In CAPD patients, hydrocortisone must be administered carefully, and if there is a reduction in ultrafiltration, a more hyperosmolar dialysate should be used.

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A 66-year-old man on regular HD was admitted to our hospital with high fever, headache and impaired consciousness. Diagnosis of acute meningitis was made, and bacterial examination of the cerebrospinal fluid revealed that the cause of the meningitis was Listeria monocytogenes 1 b. Administration of an antibiotic (ABPC 6.0g/day IV) successfully treated the condition. Listeriosis should be considered in the differential diagnosis of opportunistic infection in chronic hemodialysis patients. Appropriate antibiotic treatment is important for good prognosis.

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