Between 1989 and 1991, ultrasonograms (US) and CT films of 13 patients undergoing continuous ambulatory peritoneal dialysis (CAPD) were obtained to evaluate splenomegaly, other abdominal splanchnic systems, distribution of CAPD fluid in the abdominal cavity and the condition of the bowel and mesentery.
In this group, there were no cases with splenomegaly, while in hemodialyzed patients, splenomegaly is often demonstrated, as has previously been reported by us. Furthermore there was no statistical correlation between splenic index (SI) and duration of CAPD or platelet count in CAPD patients, though these have been recognized in hemodialyzed patients. There is a definite difference between CAPD and hemodialysis with respect to how the machines are used, so it may be concluded that splenomegaly is caused by hypersplenism resulting from blood cell injury due to mechanical stimulation with, for example, the dialyzer.
Other organs in the abdominal cavity showed no differences between CAPD patients and hemodialyzed patients.
Distribution of CAPD fluid in the abdominal cavity was different in each case, and in addition, the contact surface between it and the bowel or mesentery was localized. Furthermore, measurement of mesentery thickness tended to be affected by peristalsis, and differed according to various sites in the same patient. Therefore, mesentery thickness measured by US as an index of CAPD efficiency must be evaluated cautiously.

View full abstract

The relationship between serum carnitine levels and maintenance recombinant human erythropoietin (rHuEPO) dose was investigated in 107 hemodialysis patients. Free-carnitine (FC), total-carnitine (TC) and acyl-carnitine (AC) levels were determined spectrophotometriclly using Cobas Bio centrifugal analyzer. FC levels were 26.7±10.3μmol/l (mean±SD), TC levels were 50.9±16.0μmol/l and AC levels were 24.3±11.6μmol/l FC levels in hemodialysis patients were lower and AC levels were higher than those in healthy adults. No significant changes were observed in serum carnitine levels between a group with slight anemia (Ht≥25%, 27.2±2.6%) and one with severe anemia (Ht<25%, 22.1±1.7%) before rHuEPO treatment. Maintenance rHuEPO dose (U/kg/week) correlated with FC levels (r=-0.53, p<0.01) and TC levels (r=-0.43, p<0.05). These data suggest that carnitine may modulate the efficacy of rHuEPO in correcting renal anemia.

View full abstract

We investigated two cases with abnormal protuberances on the external segment of CAPD silicone catheters. Case 1. 43 y.o, male. A white protuberance (6mm×3mm) appeare on the catheter 62 months after catheter implantation. Leakage occurred from a pinhole opening in this protuberance. Case 2. 54 y.o, female. A protuberance with a distinctive edge appeared on the catheter 57 months after catheter implantation. The catheter was broken during drainage approximately 63 months after implantation. We studied the cross sectional structure of the two catheters with a Scanning Electron Microscope (SEM). The SE images showed bubbles, appearing consecutively around the middle of the protuberance which were observed on cross sections of the catheters. Furthermore, we performed the following tests to investigate the physical properties of these catheters. The catheters of the above two cases plus unused catheters, as controls, were studied. The following properties were assessed: 1. Hardness of 2. Tensile strength 3. Tensile strength of the radiopaque portion
We found that the hardness of unused catheters varies among manufacturers. The tensile strength of the radioaque portion was lower than that of other portions of the catheter. The catheters from Cases 1 and had lower hardness and significantly lower tensile strength than The unused catheters. Silicone rubber, a hihy biocompatible medical material, is used for CAPD application due to its superior heat resistance, cold resistance and low toxicity. However, our study indicates that silicone rubber may not maintain its integrity under the conditions (temperature, humidity, disinfection and handling) of daily catheter use. Moreover, the SEM results indicate that material degradation occurred at the inner, but not the outer, portion of the catheter. We, therefore, conclude that potential degradation of catheters may occur with long term use of CAPD catheters.

View full abstract

To elucidate the mechanisms by which long-term recombinant human erythropoietin (EPO) administration improves subjective and objective symptoms, changes in hemodynamics and plasma vasoactive endocrinological factors were investigated in 28 patients undergoing chronic hemoialysis. Patients with anemia (hematocrit value≤23.5%) were treated with EPO to maintain hematocrit values between 25 and 30%. Before and after 12 months of EPO treatment, their complaints, blood pressure, heart rate (HR), body weight, peripheral hematological examination, ECG, chest X-ray, HR changes on the Master two-step test, echo cardiography, plasma renin activity (PRA), plasma noradrenaline (pNA), angiotensin II (AII) and atrial natriuretic peptide (ANP) were examined. Hematocrit value significantly increased from 19.6±0.6% to 22.3±0.7% after one month, and was maintained at almost 27% from the second to the 12th month. Simultaneously, most complaints obviously improved. Blood pressure, HR, body weight, ECG, and cardio-thoracic ratio were not changed by EPO therapy, while changes in HR on the Master two-step test significantly decreased after the 9th month. Left ventricular stroke volume and cardiac output showed significant decreases after the third month, and either maintained this significant decrease or tended to decrease further until the end of the experiment. Total peripheral resistance showed a significant increase in the third month, then gradually returned to the basal value. PNA significantly decreased even in the early phase, while PRA and AII significantly decreased only in the late phase. ANP was not significantly changed by EPO administration.
These findings suggest that, 1) long-term EPO treatment improves subjective and objective symptoms in dialyzed patients, 2) normalization of high cardiac output state and a decrease in total peripheral resistance in the late phase may relate to improvement of symptoms, and 3) the changes in activities of the sympathetic nerve and renin-angiotensin systems seem to be one of the mechanisms underlying these hemodynamic changes.

View full abstract

Sixty-three hemodialysis cases surviving more than 15 years (Group L) were clinically evaluated. These cases were introduced to hemodialysis therapy at the age of 45.8±8.4 years, while the average age of 123 cases surviving less than 5 years (Group S) was 55.0±11.3 years. Group L was introduced to this therapy at a younger age, which most likely influenced their long survival. Among routine examinations, statistical differences were noted in BUN, S-Cr, Al-P, β₂-MG, C-PTH, HS-PTH and Al between the two groups. Significantly fewer cases needed rHuEPO to maintain a. Ht of 30% in Group L. Group L was superior in self-management of salt and water to Group S, as estimated by appropriate interdialytic weight gain and CTR. Systolic blood pressure was lower and persistent hypotension of less than 100mmHg was noted in about 8% of patients in Group L. However, there was no statistical difference in the dose of hemodialysis with respect to the Kt/V of the two groups, and there was no underialysis at the present time in Group L, eventhough it showed hypotensive tendency.
Loss of lean body mass, as estimated from the “standard body weight” obtained by Broca's equation, was particularly prominent in males in Group L, and the annual decrease in dry weight in individual cases in Group L suggested that they had undergone chronic wasting.
Parathyroidectomy for secondary HPT, surgical dissection of the carpal ligament for CTS and nephrectomy for ACDK associated with malignacy were all more frequently carried out in Group L.
Progressive bone and joint damage requiring analgesics occurred in 47% of Group S but 81% of Group L, although hospitalization for this was still rare. This problem is particularly common in longer-term survivors, and is definitely an urgent subject that needs to be addressed.

View full abstract

A commercially available data base software “KIRI” for personal computer was introduced to routine dialysis tasks such as issuing examination slips, printing test tube labels, processing examination data, registering new patients, processing information on patients, processing summaries on admission or discharge to another hospital, processing prescriptions, and inputting dialyzer maintenance data. A personal computer (NEC PC-9801 ES5) was used in combination with a printer (NEC PC-PR 700J).
Introduction of “KIRI” has spared manual labor in performing routine tasks, especially in terms of examination slips, test tube labels and prescriptions. Patient summaries were prepared just by inputting the items to be specially mentioned on each patient. Application of a commercially available generalpurpose software system is very useful in constructing a routine dialysis program at low cost and without specialized knowledge of programming.

View full abstract

In order to estimate the optimal dry weight (DW) in the initial period of hemodialysis therapy (ipHD), the relationship between cardiothoracic ratio (CTR) and excess body fluid for ultra-filtration (UF) was investigated. A few cases of overhydration were found among patients with end-stage renal disease (ESRD) caused by polycystic kidney, and the poor reliability of CTR at DW was investigated in ESRD patients with cardiac disease. In 154 patients, excluding patients with the above types of ESRD, the difference between CTR immediately before the start of HD (bsHD) and CTR after the interval required for DW to be attained (ΔCTR) was analyzed in relation to the percent decrease in body weight (ΔBW) in the same period.
A significant correlation was found between ΔCTR and ΔBW (r=0.63, p<0.025) only in ESRD with a bsHD CTR over 50%. From this correlation, the UF volume for reaching optimal DW in ipHD for overhydration ESRD with CTR over 50% is deduced from following equation: UF volume (1)=bsHD body weight×{1.28 (bsHD CTR-50)+1.3}÷100 (1). Using this, ipHD DW estimation was applied to 6 ESRD patients and was found to be applicable for reaching optimal DW in 6 hemodialysis therapies. The first three achieved 60% of target UF while the last three established 80-100% of target UF, while blood pressure and clinical symptoms were monitored.

View full abstract

We experienced a case of adult hemolytic uremic syndrome (adult HUS) which was weaned from hemodialysis (HD) by plasmapheresis (PP) therapy. A 31-year-old male patient, who had high blood pressure for ten years, was admitted for evaluation of general malaise and dyspnea. He was diagnosed as having adult HUS based on microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. Administration of antiplatelet and antihypertensive drugs, and HD therapy were begun immediately. Hemolytic anemia and thrombocytopenia gradually improved, but continuation of HD was required because of intractable oligo-anuria, which had developed, and persistent renal failure. Three months after onset, in hopes of improving his renal function, we tried PP therapy once week with HD. His daily urine output gradually increased and renal function improved. After the 9th course of PP therapy, the level of urine output, Ccr, and serum creatinine concentration had recovered to more than 1, 500ml/day, about 15.0ml/min, and 4.4mg/dl, respectively. About 7 months after onset, he was weaned from HD therapy and discharged from our hospital.
It is concluded that in the present case PP therapy was effective in treating intractable renal failure due to HUS.

View full abstract

We report a 69-year-old male patient with Leptospira interrogans serovar hebdomadis infection. Although patients infected with this serotype are considered to only rarely manifest severe illness, the general condition of the present patient deteriorated rapidly and showed a pattern of progression to criticality similar to that seen in severe cases of Weil's disease. Various clinical manifestations such as shock, acute renal failure, heart failure, pulmonary congestion, jaundice, hyperglycemia, gastrointestinal bleeding, paralytic ileus, mental disturbance, frequent recurrent apnea, and generalized convulsions, were observed. These symptoms were successfully alleviated with general supportive treatment, including administration of streptomycin and hemodialysis.
It should be stressed that leptospirosis remains even now one of the most dangerous infectious diseases in practical medicine.

View full abstract

Eosinophilic peritonitis has recently been reported as one of the entities of peritonitis which develops by an aseptic mechanism in patients on CAPD. Five cases who developed eosinophilic peritonitis within 3 weeks after insertion of a peritoneal catheter are reported from among the 60 patients who started CAPD in Mitsui Memorial Hospital. The initial sign of peritonitis was cloudy CAPD effluent in all cases, but there were no symptoms and all recovered without therapy. Although an allergic reaction to the CAPD system has been suggested as the cause of eosinophilic peritonitis, the chemical and/or mechanical stimuli associated with insertion of a peritoneal catheter may cause eosinophic peritonitis directly because 4 cases developed peritonitis within 5 days after starting CAPD. The disinfectant for the laparoscope used for insertion of the peritoneal catheter was also considered to be a possible cause of peritonitis in 2 of these cases. Antibiotics are not needed because the eosinophilic peritonitis resolves without therapy.

View full abstract

A 59-year-old man with diabetic renal failure, who underwent maintenance hemodialysis (HD) treatment for 6 years was hospitalized because of congestive heart failure (CHF). After the CHF was controlled, he abruptly developed hematochezia. Proctoscopy revealed oozing of blood from the rectal mucosa that ceased with rectal packing. Subsequently, hemorrhage recurred 5 times at different sites in the rectum. At the third episode of hematochezia proctoscopy demonstrated an actively bleeding ulcer on the posterior wall of the rectum aproximately 4cm from the anal verge. Suture ligation of the ulcer bed was required to stop the bleeding.
Later examination by colonoscopy showed multiple lesions with ulceration and friability of the rectal mucosa, whereas the remaining portion of the colon was unremarkable. No hemorrhaging was observed after the institution of total parenteral nutrition and the topical administration of ornoprostil and plaunotol. Three months later the patient died of sepsis. An autopsy specimen from the colon revealed normal mucosa and no vascular anomalies.
The recurrent hemorrhaging from various lesions in the rectum was compatible with a diagnosis of acute hemorrhagic rectal ulcer. This is a rare cause of lower bowel hemorrhage in uremic patients, and only a few cases have been reported in the form of abstracts in patients with end-stage renal disease undergoing maintenance HD in Japan.

View full abstract