The characteristics of end-stage renal disease associated with spinal cord injury were studied in 8 hemodialysis patients. The mean interval between the onset of spinal cord injury (SCI) and the institution of maintenance hemodialysis was 16.4 years. At the time of initiation of hemodialysis, the mean serum creatinine concentration was 7.2±2.5mg/dl and was markedly lower than that of the glomerulonephritic group. Mean bicarbonate was 10.9mEq/l, and mean Na was 122.1mEq/l. The main causes of the initiation of hemodialysis were fluid and electrolyte abnormalities, gastro-intestinal symptoms and heart failure. In many cases, emergency hemodialysis therapy was required. Two cases suffered from pneumonia. Surgical treatment for decubiti was undertaken in five cases, three of whom suffered from septicemia. Thus, more effective prevention and control of infections, nutrition and electrolyte balance would result in reduced morbidity and mortality rates in SCI patients. Vesicoureteral reflux (VUR) was found only in 3 kidneys of 2 cases, but hydronephrosis was present in 11 kidneys of 6 cases. Urinary tract infections associated with neurogenic bladder were the major cause of chronic renal failure in SCI patients. All SCI patients exhibited moderate to marked proteinuria, and glomerular abnormalities existed under these conditions. In conclusion, chronic renal failure complicating the course of long standing spinal cord injury represents a unique clinical condition.

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We examined cardiac function by echocardiography and plasma atrial natriuretic peptide (ANP) concentration in 56 patients on maintenance hemodialysis.
These patients were divided into two groups by plasma ANP concentration after hemodialysis. One group, having a normal concentration of plasma ANP (<75pg/ml), consisted of 37 patients (normal group.) The other group, having a high concentration of plasma ANP (≥75pg/ml), consisted of 19 patients (high group).
The level of plasma ANP was decreased in both groups by hemodialysis. There were no significant differences in left ventricular diastolic dimension (LVDd) and PEP/ET (pre-ejection phase/ejection time) between the two groups. Left ventricular systolic function did not differ in the normal group as compared to the high group. There were comparatively significant differences in posterior wall thickness (PWT), interventricular septal thickness (IVST), left ventricular mass (LVmass) and isovolumic relaxation time (IRT) between the two groups. It was considered that ventricular hypertrophy was greater and that left diastolic function was lower in the high group than in the normal group.
In conclusion, we suggest that chronic hemodialysis patients with high ANP have left diastolic dysfunction rather than systolic dysfunction.

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One hundred and six diabetic patients on maintenance hemodialysis (72 men and 34 women, mean age 58) were studied for the incidence of tuberculosis. Five patients were definitely diagnosed by positive cultures, biopsy or autopsy. Ten patients were provisionally diagnosed by the effect of antituberculosis therapy for fever of unknown origin with positive tuberculin reaction or inflammatory reaction. Therefore, we diagnosed 15 patients (14.1%) as having tuberculosis. There were no differences in age, duration of diabetes, insulin usage and other diabetic complications between the patients with and without tuberculosis. Nine patients had a past history of tuberculosis and 13 patients were diagnosed as having tuberculosis within 6 months after the beginning of hemodialysis treatment among 15 patients with tuberculosis.

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Dialysis-related amyloidosis (DRA) is characterized by the presence of an amyloid protein, β₂-microglobulin (β₂-MG), in the plasma of patients. In order to eliminate β₂-MG from the circulating blood of DRA patients, a β₂-MG selective adsorbent for direct haemoperfusion (DHP) has been developed. The adsorbent is porous cellulose beads to which the hydrophobic organic compound is covalently bound, and adsorbs more than 1mg of β₂-MG per ml of beads in vitro. A DHP column (BM-01), containing 350ml of the adsorbent, was subjected to clinical trials. The column was connected with a dialyzer (PAN or PMMA membrane) in series. The BM-01 column was used 3 times a week for 1 week (11 patients), 4 weeks (9 patients), 6 months (1 patient) and 12 months (2 patients). All patients had undergone chronic haemodialysis for periods of more than 10 years. The reduction rates in the β₂-MG level (RR) for 20 patients treated for 1 or 4 weeks were more than 64%. For 3 patients treated for more than 6 months, RR were 76.5±4.9, 73.5±5.7 and 72.2±6.2%. At the end of each session, the plasma concentration of β₂-MG was controlled below 10mg/l and 3.4mg/l was the minimum. The total amounts of removed β₂-MG (mg/session) were 172.5±22.3, 257.0±75.6, 157.6±32.2 and 429.8mg/session at maximum. Two out of these three patients showed a favorable effect on joint symptoms and in the ocular fundus. It is concluded that this selective adsorption therapy may delay the progression of DRA, and is worth considering for wide application.

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The protein binding rate of the active vitamine D₃, calcitriol, was evaluated using sera from 6 normal healthy subjects (HS) and 6 patients with chronic renal failure (CRF).
The binding rates of calcitriol at a concentration of 50pg/ml were 97.93±0.18%, 98.03±0.25% and 97.30±0.19% for sera from HS, patients receiving conservative treatment (ND) and those receiving hemodialysis (HD), respectively. The binding rates at a concentration of 200pg/ml were 96.11±0.56%, 96.28±0.42% and 95.11±0.89% for sera from HS, ND and HD patients, respectively. Thus, the protein binding rate of calcitriol was somewhat lower at a concentration of 200pg/ml than at 50pg/ml in all subject groups. However, no significant difference was seen in the protein binding rate between the two concentrations in any of the subject groups.
The binding rates of calcitriol at a concentration of 50pg/ml were 97.30±0.19% and 97.27±0.59% for sera before and after HD, respectively. At a concentration of 200pg/ml, rates were 95.11±0.89% and 95.10±0.47% for sera before and after HD, respectively. There were no significant differences among these values.
In evaluating the metabolic fate of drugs, careful consideration should be given to changes in their protein binding rate. However, our results showed little difference in the protein binding rate of calcitriol between HS and CRF patients, suggesting that the total calcitriol concentration can be used as an indicater in evaluating the disposition of calcitriol in CRF patients, without considering changes in its protein binding rate.

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From January 1991 to December 1992, we studied 23 hemodialysis patients who suffered venous hypertension with marked edema of the upper limbs after the creation of arteriovenous fistulas (AVFs). Six patients had previous temporary catheterizations through the ipsilateral subclavian and/or internal jugular veins for 24.5±9.0 (mean±SD) days. One patient had a transvenous permanent pacemaker lead through the affected subclavian vein: One had been treated with radical mastectomy and radiation therapy for breast cancer 20 years previously. However, the remaining 15 patients (65.2%) had no previous trauma to their central veins including subclavian and axillary veins. Angiographic studies in 14 patients, 3 with previous trauma and 11 with no previous trauma, revealed 8 obstructions and 5 stenoses of central veins. One patient had no angiographic abnormalities. Surgical repair was performed in 22 patients. One patient received revision of the AVF, one received percutaneous transluminal angioplasty of a stenotic subclavian vein lesion in addition to revision of the AVF, and 4 patients had fistula revision and banding using a polytetrafluoroethylene sheet at the anastomosis site. However, the other 16 patients required closure of AVFs for improvement of their edema.
Many cases with venous hypertension showed occlusion or stenosis of central veins without a history of central vein trauma. This study suggests that repetitive intimal trauma caused by the powerful post-fistula jet may contribute to the formation of chronic fibrosis and intimal hyperplasia of the central veins. Furthermore, the naturally occuring stenosis at the merging of the central veins may accentuate this process.

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In order to clarify the effect of CAPD on plasma thrombomodulin, which is regarded as a marker of endothelial cell injury, we investigated plasma thrombomodulin antigen levels (TM) in uremic patients maintained on CAPD (n=16), in comparison with TM in uremic patients maintained on regular hemodialysis treatment (HD) (n=25). TM were significantly higher in HD patients than in CAPD patients (HD: 20±7 (mean±SD) ng/ml; CAPD: 15±3, p<0.01). A significant positive correlation was found between the duration of dialysis and TM (HD: r=0.809, p<0.001; CAPD: r=0.431, p<0.05) in both HD and CAPD patients. However, the slope (A) of the regression line (TM=A×duration of dialysis+B) was steeper (0.05<p<0.1) in HD patients than in CAPD patients. These results suggest that CAPD and HD appear to have different effects on vascular endothelial disorders.

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Cardiovascular disorder is considered the most important risk factor in patients on hemodialysis (HD). Lipid abnormalities may be involved in the rapid development of cardiovascular disorder in dialysis patients, especially those on continuous ambulatory peritoneal dialysis (CAPD).
Hyperechoic lesions of the aortic valves on the short axis view obtained by echocardiography are regarded as a marker of atherosclerotic change. We compared 17 HD patients and 16 CAPD patients with respect to hyperechoic lesions of the aortic valves on echocardiography, serum Ca and P levels and serum lipid levels to evaluate the level of coronary atherosclerosis. The mean age of HD patients was 48.1±7.6 years and that of CAPD patients was 40.7±10.4 years. The duration of dialysis was 153.9±69 months for HD patients and 49.5±40.8 months for CAPD patients. Hyperechoic lesions of the aortic valves were found significantly more frequently (p<0.05) in CAPD patients than in HD patients (87.5% vs 58.5%), although dialysis lasted for a significantly shorter (p<0.05) period in CAPD patients than in HD patients. Serum levels of Ca, P, total cholesterol, HDL cholesterol, LDL cholesterol and Lp(a) were not significantly different between HD and CAPD patients. Serum levels of triglyceride (TG) and β-lipoprotein were significantly higher (p<0.01) in CAPD patients than in HD patients (TG: HD patients 109.4±8.9mg/dl; CAPD patients 186.1±113.1mg/dl; β-lipoprotein: HD patients 206.8±105.1mg/dl, CARD patients 463.5±160.3mg/dl). These results suggest that coronary atherosclerosis may occur more frequently in CAPD patients than in HD patients and that elevated levels of TG and β-lipoprotein in serum are probably related to the development of coronary atherosclerosis in CAPD patients.

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The pressor mechanism of amezinium metilsulfate (Am), a new antihypotensive agent which stimulates the sympathetic nerve endings, was investigated in 21 patients on maintenance hemodialysis. Hemodynamic parameters were obtained using echocardiograms before and after the oral administration of Am, 10mg once a day, for 5 weeks. Three patients were excluded because of minor adverse effects (urinary retention and headache); these effects disappeared immediately after Am was discontinued. Mean blood pressure (MBP) at the onset of dialysis increased from 88.2±9.5 to 95.1±16.1mmHg (m±SD; p<0.05) and the trough MBP during dialysis increased from 60.1±11.7 to 69.7±14.2mmHg (p<0.01). No changes were observed in left ventricular diameter, heart rate or cardiac output. The total peripheral resistance index (TPRI) increased from 845±267 to 968±230×10^-4dynes·sec/cm⁷ (p<0.05). The significant correlation between the increases in blood pressure and TPRI indicates that the increase in blood pressure with Am is caused by peripheral vascular constriction. Am demonstrated a weak but definite cardiac stimulatory effect in patients with a cardiac index of less than 4l/min/m² before treatment. The finding that blood pressure increased more in the more hypotensive patients suggests that dialysis hypotension is mainly caused by a decrease in sympathetic nervous activity.

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We report herein two cases of colitis associated with chronic renal failure. One case had ischemic colitis (IC), the other ulcerative colitis (UC).
A 28-year-old female with a history of diabetes mellitus, hypertension, congestive heart failure, constipation and chronic renal failure developed IC. She was admitted to our department because of bloody diarrhea with severe abdominal pain that was recognized several minutes after initiating hemodialysis. Barium enema examination revealed segmental narrowing in the left colon. Colonoscopy showed a longitudinal ulcer in the same portion. These findings were considered typical of IC. It is generally said that IC most often affects the elderly because of the greater frequency of vascular disease in that group, but IC may affect younger hemodialysis patients because of the numerous risk factors for IC, such as arteriosclerosis due to secondary hyper-parathyroidism, hyper-intraintestinal pressure based on uremic autonomic nervous disorder inducing hypokinetic intestinal movement, and decreased micro-circulation in the colon induced by the above factors. Therefore, we must consider the possibility of IC in hemodialysis patients with vascular disease associated with rectal bleeding, even when the patient is young. In the second case, a 32-year-old male was admitted because of abdominal pain and melena with fever. Colonography revealed serrations along the contour of the transverse and descending colon. Endoscopic examination revealed diffuse erythema, friability of the mucosa and multiple ulcers occurring from the middle portion of the transverse colon to the descending colon. A biopsy specimen from the descending colon showed mucosal inflammation and crypt abscess. These findings indicated UC. While the cause of UC remains unknown, immunologic and psychological factors have been suggested in several reports. In our case, the CD4/CD8 ratio was normal, and UC developed during the patient's busiest season. Therefore, psychogenic factors may be related to the etiology in this case. UC is very rare among hemodialysis patients, but the possibility of UC must be considered in cases of chronic renal failure complicated with bloody diarrhea.

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A 37-year-old female with acute spinal epidural hematoma (ASEH) who had undergone hemodialysis for twelve years is reported. She complained of neck and back pain just after starting hemodialysis and experienced lower paraplegia five hours later. She rapidly developed sensory disturbances below the Th4 level, quadriplegia and respiratory disturbances due to paralysis of the intercostal muscles. MRI examination revealed hematoma on the posterior side of the spinal epidural space from C3 to Th2. Under a diagnosis of ASEH, operation was performed ten hours after the onset. Laminotomy from C4 to Th3 and laminoplasty were performed. As an anticoagulant for postoperative hemodialysis, Nafamostat mesilate (Futhan^®) 20mg/hr was used for the first seven days and heparin was subsequently used. Only paresis of the upper extremities improved. Other neurological deficits have remained. Moreover, endotracheal intubation and mechanical ventilation were temporarily indicated because the paralysis of the intercostal muscles led to atelectasis. Finally, tracheotomy was performed and she survived.
Only five cases, including ours, of ASEH in hemodialysis patients have been reported in the Japanese literature. Because of massive hematoma and systemic heparinization neurological recovery was poor and respiratory management was required in our case, although the interval between the onset and operation was brief. MRI examination was extremely helpful diagnostically and useful for making decisions regarding surgical treatment.
To achieve a better prognosis for ASEH, appropriate diagnosis and prompt treatment are indispensable and it is important to keep ASEH in mind in the management of hemodialysis patients.

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A case of ventricular tachycardia induced by antiarrhythmic drugs during hemodialysis is reported. The patient was a 56-year-old woman who was initiated on regular dialysis because of chronic renal failure at the age of 49. At 56 years of age, she suffered from dyspnea related to inadequate dialysis. One week after admission, she experienced a syncopal attack due to ventricular tachycardia induced by an antiarrhythmic drug. Two months later, she also experienced a syncopal attack due to ventricular tachycardia induced by pilsicainide. DC shock was required on both occasions. Recently, the provocation of serious arrhythmias by antiarrhythmic drugs has been recognized. This phenomenon is termed “proarrhythmia”. However, to our knowledge, no reports have appeared of proarrhythmia during hemodialysis. When antiarrythmic agents are used, serum drug concentrations should be carefully monitored at regular intervals.

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This report describes a patient with chronic renal failure who showed severe bleeding tendencies after 16 years of hemodialysis. He was a 40-year-old man who had been on hemodialysis since 1972 under a diagnosis of chronic renal failure due to chronic glomerulonephritis. Bleeding tendencies such as systemic purpura and gingival bleeding appeared in August 1988. His platelet count was 10.1×10⁴/μl, and platelet agglutination and adhesion capacity were severely depressed. A high serum IgA value (1, 148mg/dl) and the appearance of an M bow in IgA γ in immunoelectorophoresis led us to suspect myeloma. We treated his bleeding tendencies with non-heparinized hemodialysis and plasma exchange, but he showed upper gastrointestinal bleeding. He also received chemotherapy (cyclophosphamide, vincristine), but he died of liver failure in June 1989. Pathological examination revealed systemic AL amyloidosis and diffuse bone marrow invasion of mild atypical plasma cells. In multiple myeloma, nodular proliferation of plasma cells is characteristic, but it was not observed in this case.
We assumed that the bleeding tendencies were due to amyloid infiltration of the blood vessels.

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