Continuous peritoneal dialysis has become one of the most popular therapies for childhood the renal failure in childhood, because of its outstanding merits such as blood access unneeded, economic superiority and ease of manipulation. Despite these merits, in some cases long-term CAPD was found to cause a fatal defect, i.e. a permeability change followed by overhydration.
We studied the effects of glucose concentration on the change in peritoneal permeability by making rat CAPD models. Different doses of glucose were administered to the rats via a peritoneal tube and peritoneal function was evaluated.
In conclusion, hypertonic dialysates with glucose concentrations of 7.0% increased permeability without changing lymphatic absorption. High dialysate glucose concentrations enhanced peritoneal permeability and decreased the ultrafiltration volume.

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Ischemic peripheral circulatory disorders have been observed more and more frequently in maintenance hemodialysis patients in recent years. This tendency coincides with the increasing progression of arteriosclerosis in maintenance hemodialysis patients. Clinical investigations were therefore presumed to be useful in elucidating the pathogenesis of the symptoms. Among 20 patients diagnosed with ischemic peripheral circulatory disorders, arteriosclerotic obstruction (ASO) was diagnosed in 12 patients and the steal syndrome (SS) in 11 patients. Three patients had both.
Suspected risk factors were as follows: sex, male vs female=11/9; age>65 years old, 7/20; chronic renal failure, 20/20; dyslipidemia, 6/20; diabetes mellitus, 7/20; double/triple internal shunt, 4/20, accelerated coagulability, 8/8; accelerated fibrinolysis, 4/7.
Symptom severity was graded according to Fontaine's classification, and the results were as follows: in ASO patients, grade I: 1 patients, grade II: 5, grade III: 2, grade IV: 4, and tentatively applying the same classification to the SS patients, grade I: 1, patient grade II: 3, grade III: 7, and grade IV: 0.
SS was suspected of more readily developing after creation of the internal shunt in patients who already had arteriosclerosis in arteries distal to the fistula.
Examinations useful in reaching a diagnosis were ankle pressure index, thermography, plethysmography, angiography and magnetic resonance imaging. Digital subtraction angiography is indicated in diagnosing SS in which a natural blood flow pattern is ascertained.

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Serum parathyroid hormone (PTH) levels in 381 hemodialysis patients were determined using 4 different immunoreactive PTH assay systems. The assay systems assessed were PTH-MC (Mitsubishi), HS-PTH (Yamasa), C-PTH (Eiken) and intact-PTH (i-PTH; Mediphysics). The characteristics of the PTH-MC assay, a new assay developed to detect mid-region PTH, were examined and the interrelationships between the 4 PTH assays were analyzed. The range of measurements using the PTH-MC system was very broad (0.1-50ng/ml), and the accuracy of the data was excellent (intra-assay coefficient of variation [CV] 1.5-2.5% and interassay CV 2.0-5.5%). The PTH values determined by the different PTH assays were strongly correlated with each another. When the correlations between the i-PTH and three other assays each were compared in patients whose PTH levels were low (consistent with i-PTH levels of less than 100pg/ml), the PTH-MC assay yielded the highest correlation with i-PTH. Disproportionately higher i-PTH values compared to the values of the other assays were found in some patients in this analysis. As a consequence of the high correlation between i-PTH and PTH-MC at low PTH levels, the PTH-MC system was the least likely to miss these cases. The i-PTH assay reflects the realtime PTH secretory state, however, the values are easily influenced by changes in serum calcium levels. The three other assays reflect the amount of accumulated PTH fragments, therefore, the PTH values determined by these systems should be increased in hemodialysis patients. Based on this characteristic, the early detection of PTH hypersecretory states by these PTH assays is easier than by the i-PTH assay. Some patients in this study had undetectable i-PTH levels, however, the values determined by PTH-MC were within the range of detection. Even the patients with low levels of PTH may develop overt hyperparathyroidism during long-term dialysis. These results suggest that the PTH-MC system is a preferable assay for serial monitoring of these patients, because the measurable range of PTH-MC assay was broad and its accuracy at low PTH levels was superior to the HS-PTH and C-PTH systems.

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In order to evaluate the effect of rHuEPO on the plasma level of BCAA in maintenance hemodialysis patients, the plasma levels of BCAA and AAA and the Fischer ratio were measured in 15 hemodialysis patients (age, 45.8±9.5 years old; duration of hemodialysis, 38.1±50.5 months; mean±SD) before as well as after rHuEPO therapy for 8.4±4.4 months. The plasma level of each amino acid of BCAA was significantly decreased: valine (193.3±36.5→168.4±34.0nmol/ml), leucine (109.1±24.5→93.8±26.1nmol/ml) and isoleucine (61.3±13.7→55.1±15.8nmol/ml), (p<0.05). On the other hand, the plasma level of each amino acid of AAA failed to reveal a significant change after rHuEPO therapy. The Fischer ratio (valine+leucine+isoleucine/phenylalanine+tyrosine) showed a subtle decrease, from 3.45±0.75 to 3.18±0.83 after rHuEPO therapy, but failed to reach statistical significance. Although the number of patients was too small to draw definite conclusions, the present study implied that rHuEPO treatment in maintenance hemodialized patients results in a significant decrease in the plasma level of BCAA. Thus supplemental BCAA would be necessary when rHuEPO therapy starts.

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To evaluate the effect of secondary hyperparathyroidism on glucose intolerance in chronic renal failure (CRF), the intravenous glucose tolerance test (IVGTT) and glucagon loading test (GLT) were employed in 15 chronically hemodialyzed (HD) patients: 8 with high parathyroid hormone (PTH) levels (Group 2HPT) and 7 with relatively normal PTH levels (Group EPT). An euglycemic clamp study was also performed in 5 HD patients with secondary hyperparathyroidism before and after parathyroidectomy (PTX). The results were as follows. 1) In IVGTT, the K-value of Group 2HPT did not differ significantly from that of Group EPT. 2) The insulin (IRI) secretion in IVGTT, either the peak level or the area under the curve (AUC), showed no difference between Group 2HPT and Group EPT. 3) In GLT, the results of IRI secretion were similar to those in IVGTT. 4) Euglycemic clamp studies showed significant increases in mean glucose infusion rate (M-value) and metabolic clearance rate (MCR) after PTX.
These results suggest that pancreatic islets of Group 2HPT patients still have as much insulin secreting capability as those of Group EPT patients. Furthermore, PTX seems to improve the tissue insulin resistance significantly. We conclude that it is highly likely that a high PTH level in HD patients is concerned with glucose intolerance in CRF not as an insulin secretion blocker but as an enhancer of tissue insulin resistance.

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Continuous ambulatory peritoneal dialysis (CAPD) is superior to hemodialysis (HD) in terms of its morbidity rate. The use of CAPD in Japan has increased in recent years. Unfortunately, there are some drop-outs. This retrospective study investigated cases of withdrawal and death in 60 CAPD patients (37 males, 23 females) treated at Hiroshima University's Second Department of Internal Medicine and Ichiyokai Harada Hospital between August 1985 and October 1991. Fifty-two patients were selected positively and 8 patients negatively. Of the 60 patients, 49 remained on CAPD while the following drop-outs occurred: 5 due to death (8%), 4 due to transfer to HD (7%) and 2 due to kidney transplantation (3%). The deaths were related to myocardial infarction, heart failure, cerebral hemorrhage, meningitis and suicide. Three of the 4 patients transferred to HD due to peritonitis. Proper patient selection and the prevention of peritonitis are important factors in maintaining a patient on CAPD.

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Lipoprotein(a) [Lp(a)] is an independent risk factor for atherosclerosis in the general population and represents a greater risk to hemodialysis patients (HD patients). Because the relationship between risk factors attributed to atherosclerosis for ischemic heart disease (IHD) and Lp(a) has not been established, we compared levels of Lp(a) and the frequency of occurrence of its isoforms in 317 patients and 212 normal subjects. We used thallium-201 single photon emission computed tomography for the assessment of IHD. The following results were obtained: 1) HD patients showed significantly elevated levels of Lp(a) when compared with normal subjects. There were no significant differences in the levels of Lp(a) occurring in other etiological diseases. 2) Studies of the apo(a) isoform showed that HD patients had high frequencies of S₂ and S₂/S₃. 3) No significant differences were observed between the levels of Lp(a) and the apo(a) isoform in IHD(-) and IHD(+) in HD patients. The abnormal characteristics of lipid metabolism found in HD patients who died from IHD were high levels of Lp(a), LDL-cholesterol and high double band frequencies.
These results indicate that Lp(a) may represent a risk factor for IHD in HD patients.

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Short-time dialysis (3hrs) was evaluated with respect to various clinical factors.
Using a high performance membrane (HPM), under the conditions of blood flow (Q_B)=314ml/min and dialysate flow=500ml/min, 1) KT/V, TAC_BUN, PCR were 1.35±0.17, 46.6±7.1mg/dl, 1.20±0.18g/kg/day, respectively. The average reduction in β₂ microglobulin was 42.6±6.3mg/dl. 2) Cardiac functions examined by the Swan-Ganz catheter method showed that an increase in Q_B did not affect MBP, HR, CI, CVP, PCWP or PA. 3) The endotoxin concentration of the dialysate was 2.7pg/ml. 4) No difference was found in clinical data (CTR, blood pressure and blood test parameters) between conventional HD and short-time HD. 5) Shortening of the HD time seemed to be beneficial to the patient's quality of life.
We conclude that shortening of the HD time does not influence the adequacy of HD, if HPM and high Q_B are properly chosen. We also suggest that an increase in Q_B has no substantial effect on cardiac functions.

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We report a case of prednisolone-responsive cisplatin-induced acute renal failure.
A 64-year-old man who suffered from advanced gastric cancer, received continuous hyperthermic peritoneal perfusion (CHPP) of cisplatin (300mg) at the time of total gastrectomy. Normal renal function deteriorated acutely following the operation. Five days after the operation, he became anuric and the serum levels of BUN and creatinine rose to 70mg/dl and 9mg/dl, respectively. He therefore underwent hemodialysis. Two weeks after the initiation of hemodialysis, diuresis occurred, but serum creatinine levels did not improve. Renal biopsy was performed at 74 days after the operation, when creatinine was 10mg/dl and it disclosed almost normal glomeruli and marked cellular infiltration of the interstitium, especially in the region of the corticomedullary junction. Therapy with prednisolone resulted in a fall in the serum creatinine level, which decreased from 10mg/dl to 5mg/dl. Our case suggests the effectiveness of prednisolone therapy for cisplatin-induced acute renal failure.

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Gangrene is one of the most serious complications in diabetic patients. We report a 58-year-old male undergoing hemodialysis with a 20-year history of diabetes who suffered gangrene of the tip of his left fourth finger after amputation of both lower extremities. Not only arteriosclerosis due to end-stage renal disease and long-standing diabetes but arteriovenous fistula steal effects were thought to be responsible for the fingertip gangrene. In this case, the gangrene healed successfully after 10 months of conservative treatment including intravenous administration of prostagrandin E₁.
Intensive attention should be paid for preventing gangrene of upper extremity as well as lower extremity in diabetic patients undergoing hemodialysis.

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We report a case of successful pregnancy and delivery in a chronic hemodialysis patient. A 23-year-old woman with a 7-year history of maintenance hemodialysis was admitted because of an eclamptic convulsion at 20 weeks of pregnancy (blood pressure at the time was 240/140). The fetus suffered intrauterine growth retardation (IUGR). At 34 weeks of pregnancy the patient delivered a girl weighing 870g by cesarean section. The infant had an Apgar score of 8 at one minute and 10 at five minutes. No congenital malformations were detected.
The most common complications are threatened abortion and premature birth, polyhydramnios, liver dysfunction and atonic hemorrhage. In addition to the prevention and treatment of these complications, it is very important to maintain the BUN below 60mg/dl by performing adequate hemodialysis and the hematocrit above 30% by using recombinant erythropoetin (rh-EPO) to achieve successful pregnancy and delivery in chronic hemodialysis patients.

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This is the first case report of tuberculous peritonitis in a child on CAPD with abdominal wall abscess. The abscess was related to subcutaneous leakage of the dialysate during replacement of the CAPD catheters. Tuberculosis must be considered in CAPD patients including children with culture-negative, non-resolving peritonitis.

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A case of Epstein-Barr virus (EBV) encephalitis occurring in a 74-year-old man under hemodialysis (HD) is described. Diagnosis of EBV encephalitis was based on high serum EBV antibodys titers and clinical features. The main symptom was rapid clouding of consciousness. He did not have any systemic symptoms suggestive of infectious mononucleosis. Because he lacked neck stiffness and the cerebrospinal fluid was clear, there was no sequence of meningitis. It has been reported that EBV encephalitis is self-limited and relatively benign. Two months after onset, the disease disappeared and he was improved by respiratory management and preventive measures against other complications; however, dementia remained.
There seem to have been no reports of EBV encephalitis in HD patients.

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