For the purpose of establishing a supplementary diagnosis of renal osteodystrophy and evaluating its pathology, we conducted regular height measurements over a two year period on 43 maintenance dialysis patients, and comparatively investigated changes in height and various laboratory data.
Height was measured every 3 months, and differences in height measured from January, 1988 through January, 1990 were assessed in this study. Height changes were comparatively studied in terms of age, dialysis history, and such clinical test results as serum Ca, P, ALP, C-PTH, AI, BMG, and CT (calcitonin), etc.
Bone salts (∑GS/D) were measured by the digital image processing method, and compared with changes in height. We also studied the relationship between vitamin D₃ dosage and changes in height.
There was a positive correlation between reduced body height and duration of dialysis, specifically, r=0.307. The serum Ca level also correlated positively with dialysis duration (r=0.345). Reduced body height and serum ALP showed a positive correlation, r=0.670, and p<0.01, as was the case with the serum C-PTH level, the positive correlation of which had an r=0.701, with p<0.01.
A negative correlation was observed between ∑GS/D and height reduction, serum ALP, and the C-PTH level.
No correlation was observed between vitamin D₃ dosage and height reduction.
In 4 out of 5 patients whose height decreased by 2cm or more during the 2 year period, abnormally high serum C-PTH levels were observed.

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We undertook a study of the optimal route of administration and dosage of recombinant human erythropoietin (EPO) for the treatment of renal anemia in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).
Sixteen clinically stable patients (9 males, 7 females; mean age 45 years) undergoing CAPD were selected for this study. Weekly intravenous (i.v.) administration of EPO was switched to weekly subcutaneous (s.c.) administration. Changes in hemoglobin (Hb) concentration were observed. The rates of increase in Hb concentration between twice weekly i.v. EPO 6, 000U and weekly s.c. EPO 6, 000U were compared. Twelve patients who received EPO subcutaneously were divided into four groups. Group 1 (n=5) received 6, 000U weekly. Group 2 (n=3) received 9, 000U biweekly. Group 3 (n=3) received 6, 000U biweekly. Group 4 (n=1) received 9, 000U monthly. The maintenance dose and schedule of subcutaneous treatment in all patients were studied. The maintenance dose of EPO was also determined in hemodialysis (HD) and CAPD patients.
The initial and maintenance therapy with subcutaneous administration are more effective than intravenous treatment in CAPD patients. Biweekly s.c. EPO 6, 000-9, 000U administration showed a sufficient response in correction of anemia, and Hb levels were maintained by biweekly s.c. EPO 1, 500-9, 000U (mean: 6, 094U) administration. Maintenance doses in CAPD patients who received s.c. EPO showed a tendency to decrease as compared with those of HD patients who received i.v. EPO. No anti-EPO antibodies were detected in any patients.
Taking quality of life into consideration, s.c. EPO is recommended for correction of anemia in CAPD patients.

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The effects of high sodium hemodialysis (HD) on blood pressure, hematocrit, plasma osmolality and vasoactive substances were studied in 10 chronic HD patients and compared with those of standard HD.
High sodium HD was carried out for the first 2 hours with a high sodium dialysate (Na 155mEq/l) consisting of a constant injection of high salt solution into the standard dialysate, and then standard dialysate (Na 140mEq/l) was used for the last 2 to 3 hours.
Blood pressure was measured at one hour intervals for 24 hours using an ambulatory blood pressure monitor.
Although there was no significant difference in pre- and post-dialysis body weight and removed fluid volume between high sodium HD and standard HD, significantly higher blood pressure was observed during high sodium HD and the hypertensive tendency persisted after HD.
As compared with the standard HD, the high sodium HD showed a significantly higher concentration of plasma sodium at 2 hour- and post-dialysis tests (p<0.01 for both) and a significantly higher plasma osmolality at 2 hour-dialysis test (p<0.05). The hematocrit, however, was significantly lower at pre- and 2 hour-dialysis tests (p<0.001 for both).
While atrial natriuretic peptide (ANP) significantly decreased during both forms of HD, plasma renin activity (PRA) did not change significantly with either HD. Plasma aldosterone concentration (PAC) significantly decreased with high sodium dialysate, but not with standard dialysate.
Plasma noradrenaline (NA) and adrenaline (A) were significantly decreased at 2 hour-dialysis test and increased to the pre-dialysis levels after HD. There was no significant difference between the high sodium HD and the standard HD in the plasma levels of ANP, PRA, PAC, NA, and A at the pre-, 2 hour- or post-dialysis tests.
These results suggest that intracellular and extracellular fluid moved into the vascular space more quickly and compensated for the reduction of circulatory plasma volume on high sodium HD.

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A 30-year-old man was treated with HDF, using 4L of displacement liquid and a polysulfone membrane dialyser (F60), for 4 hours every day because of MOF. MRSA, being responsive only to VCM, was detected by blood culture. Therefore, 500mg VCM dissolved in 250ml, a 5% glucose solution, was applied by drip infusion for 1 to 1.5 hours after HDF, every other day for one month. Blood concentrations of VCM were measured before each HDF.
The average VCM blood concentration was 25.5±4.3 on the first day and 16.8±2.7μg/ml on the second day. Deposition of VCM in blood was not detected, despite long-term administration. Blood concentrations of VCM decreased gradually after discontinuance and had fallen to 3.2μg/ml by the 7th day. No side effects of VCM occurred during the observation period.

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We carried out 2-D phase contrast MR-angiography of internal A-V fistulae with a 1.5T MRI unit (GE SIGNA PERFORMANCE PLUS). The usefulness of this method as compared with angiography (DSA) is discussed. Eight hemodialysis patients were examined. The images of MR angiography were somewhat inferior to those of DSA because of lower spatial resolution, but MR angiography clearly demonstrated internal A-V fistulae and vessel stenosis without the necessity of injecting contrast medium into the artery. It is concluded that MR angiography may be a relatively noninvasive, though still reliable, technique for evaluating internal A-V fistulae.

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Two hundred and seventy-three hemodialysis patients from 18 dialysis centers were enrolled in this study. The subjects were divided into 3 groups according to an initial dosage. The initial dosage administered caused a dosedependent rise in hematocrit values after four weeks.
There was, however no statistically significant difference among the three groups after 12 weeks. For maintenance treatment, the amounts of erythropoietin administered were lower than in the initial treatment. The weekly average dose during the 13-24th week period was less than or equal to 4, 500IU/week in about 80% of patients. But 25% of the patients needed 6, 000IU/week to maintain hematocrit values of 30%. Adverse effects occrred in 34 (12.5%) of 273 patients. The two major problems were a rise in blood pressure (22 cases) and headache (6 cases).
We recommend an initial dose of 3, 000IU/week. This dose should result in a slow but substantial rise in hematocrit.

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In two patients in whom conventional vascular access for maintenance hemodialysis was not possible, access in the form of a great saphenous vein-popliteal artery bypass was achieved under local infiltration anesthesia. A straight saphenous vein placed subcutaneously in the thigh has been used with the advantage that the proximal end of the saphenous vein is left in situ and only the distal end requires end to side anastomosis to the proximal popliteal artery. A follow up of 18 to 19 months and experience with more than 460 courses of hemodialysis treatment have shown it to be a suitable and satisfactory access.

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The immune function of peripheral blood lymphocytes (PBL) of patients on maintenance hemodialysis was studied. The hemodialyzed patients were subdivided into 2 groups; patients receiving hemodialysis treatment for time periods either equal to or less than 3 years (Group I) and equal to or greater than 10 years (Group II). Healthy volunteers (Group III) were used as controls. We assayed several immunological parameters, including IL-1 activity of monocytes stimulated with OK432, lymphokine-activated killer (LAK) cell activity against renal cancer cells, and titers of cytokines (IFN-gamma and TNF-alpha) produced by either PBL cultured with IL-2 or LAK cells cultured with the renal cancer cells. In group I both LAK cell activity and IL-1 production were significantly suppressed as compared to those in group III. In addition, the titer of IFN produced by LAK cells was lower than that in group III. There were no significant differences among the titers of cytokines produced by PBL in any of the three groups. Although the percentage of cases with suppressed cytokine production seemed higher in Group I than Group III, the difference was not significant. However, there was a close correlation between the values of IFN-gamma and TNF-alpha in patients undergoing hemodialysis. Therefore, there could be some patients with impaired immune function of PBL in Group I. In contrast, there was no significant difference in the immune functions of PBL that we examined between patients on long-term hemodialysis (≥10 years) and healthy volunteers.

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We conducted a survey of chronic renal failure patients on maintenance hemodialysis in Osaka Prefecture with regards to the occurrence of acquired cystic disease of the kidney (ACDK) and the possible complication of renal cell carcinoma from January 1, 1990 to December 31, 1990. In Osaka Prefecture, maintenance hemodialysis is done at 133 different clinics on a total of 7, 379 patients. Of these 133 clinics, 118 (88.7%) responded to our ACDK survey. Fifty-nine (50%) of the 118 clinics conducted examinations verifying the presence of ACDK once or twice a year (average: 1.6 times). For this examination, ultrasonography was used at these 59 units, and computed tomography was also used at 58 units.
We studied the occurrence of ACDK and the number of nephrectomies performed on all 3, 271 patients of the 59 clinics. Of these 3, 271 patients, 758 (23.2%) were diagnosed as having ACDK. The ratio of male ACDK patients to female ACDK patients was about 2:1 (501:257). In those patients who had been on hemodialysis for 12 years or less, the longer the duration, the higher the incidence, with the highest rate (44%) found in those who had been on hemodialysis for 10 to 12 years. The rate was 34-36% in patients who had been on hemodialysis for over 12 years. Renal cell carcinoma was a complication in 15 patients (male: 15, female: 0). These patients underwent nephrectomy. The renal cell carcinoma rate tended to be higher in patients who had been on hemodialysis for a long period of time.

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We have attempted to assess the psychological aspects of nursing problems in elderly patients beginning regular hemodialysis, based on the evaluation of clinical episodes of 5 elderly cases. In general, elderly patients have less ability to adapt to the new circumstances. When they must accept new circumstances, various psychological problems occur. We observed, on induction of hemodialysis, that patients who were poorly informed before the induction of hemodialysis manifested much more anxiety than patients who were fully informed. The more anxiety the patients had, the more clinical symptoms they complained. With regard to social aspects, we observed changes in relationships between patients and their families, which aids and supports given by the families ameliorated during the phase of hemodialysis induction. Under these circumstance the roles of patients in their families and/or society had to change. Their responses to these changes in relationships had numerous aspects and the responses of the each patient were unique. Some patients accepted the changes, but others struggled against change. We must consider the socio-economical circumstances of patients before they begin hemodialysis therapy. In conclusion, the important point in nursing elderly patients beginning dialysis is to offer sufficient information about the therapy and to help patients adjust to and accept changes in their familial and/or societal roles.

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We report a patient with chronic renal failure (CRF) who had refused hemodialysis (HD) and blood access who was subsequently persuaded to accept dialysis therapy.
In March 1990, a 45-year-old male with chronic glomerulonephritis who had been undergoing treatment at another hospital since 1979 was referred to us for HD treatment. However, he refused HD and discontinued receiving medical treatment.
On June 16, he was admitted to our hospital with loss of consciousness. Emergency HD was performed under a diagnosis of uremia. His consciousness was restored and other symptoms of CRF improved. Although we stressed the importance of maintenance HD and the patient apparently understood the factors involved in this treatment, he again refused HD and blood access 5 days later.
Thereafter, from June 21 to August 31, members of our staff attempted to persuade him to accept dialysis therapy using a comprehensive consultation-liaison psychiatric approach; consisting of hospitalization, frequent counseling from a private nurse, and the supportive efforts of a therapeutic team comprised of his doctor, physicians specializing in psychosomatic medicine, and nurses.
The patient was undergoing a process of grief related to the loss of his health. Because of his lack of understanding of his condition, our explanations of renal function and HD were to no avail. We therefore made an effort to help him to control his reaction to his situation. As a consequence, although he continued to refuse HD, he did not reject us.
This comprehensive approach provided supportive understanding of his feelings and may have hastened the progress of his grief. At last he was psychologically prepared to accept HD and on September 1, faced with progressing renal anemia, he began HD therapy.
Our success in persuading this patient to accept HD therapy suggests that a supportive consultation-liaison service is a useful approach in the total health care of patients about to start HD treatment.

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A 46-year-old woman had a transvenous pacemaker implanted through her right subclavian vein for treatment of sick sinus syndrome 2 years after beginning maintenance hemodialysis. The following year, she receved parenteral nutrition through her left subclavian vein for 12 days due to ileus which was on the same side as the atriovenous fistula. Then, she gradually developed left superior limb edema. Bilateral venography of the upper limbs, performed in 1988, showed right subclavian vein and left innominate vein occlusion and rich collateral circulation on both sides. The symptoms slowly worsened and were accompanied by headache, pigmentation of the left palm and phlebothrombosis of the left arm. Report venography revealed bilateral subclavian vein occlusion. Therefore, we performed occlusion of the atriovenous fistula and subcutaneous fixation of the left brachial artery. Two months postoperatively, all symptoms had improved and she had no difficulty with hemodialysis. In conclusion, we have to bear in mind the potential risk of subclavian vein thrombosis following subclavian vein catheterization in patients on maintenance hemodialysis, especially those who have already undergone transvenous pacemaker implantation.

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A 40-year-old female was diagnosed as having systemic lupus erythematosus in 1965, and treated with steroid therapy till 1975. She was admitted to our hospital for renal dysfunction and anasarca in Nov. 1987. Laboratory examinations revealed pancytopenia and a high anti nucleic factor (ANF) titer. Renal failure and cardiac tamponade were recognized on physical examination. The patient was treated by hemodialysis immediately after admission for renal failure.
Her general condition was too critical to start steroid therapy, so we initiated plasmapheresis on the 7th day of hospitalization. After one immuno plasmaperfusion and two courses of double filtration plasmapheresis had been done, her general condition was slightly improved, and we were able to start steroid therapy.
We continued hemodialysis and plasmapheresis, and she was ultimatoly to discontinue regular dialytic therapy.

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A 66-year-old male patient on CAPD was treated conservatively for the complication of an abdominal wall hernia which appeared at the internal cuff site. Blood access in this patient seemed nearly impossible due to frequent previous shunt operations. The volume of dialysate was reduced from 8l/day down to 5l/day under scrupulous observation. The levels of BUN and β₂-MG were found to be only mildly elevated while other laboratory parameters and water removal appeared to be maintained at clinically acceptable levels.
Our experience suggests that conservative treatment can be chosen in some cases of abdominal wall hernia as shown in this report. The possibility of conservative treatment, properly modified for each case, should be taken into consideration before opting for surgery.

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Subdural hematoma has been found in three of 143 dialysis patients (2.2%) in the past 15 years. One of them had a chronic subdural hematoma and, after the first operation, a subacute one was found on the opposite side which was removed at a second operation. Later, hydrocephalus developed which was healed by ventriculoperitoneal shunt. The other two cases had chronic and acute subdural hematomas, respectively. There was no worsening and both healing spontaneously. The characteristics of subdural hematoma occurring in dialysis patients to be noted are 1) bilateral and 2) the patients can be any age. Therefore, the main causes presumably are 1) lower coagulation due to heparinization and 2) intracranial pressure change due to dialysis. The syndrome includes intractable headache, mental disorder and light motor paralysis. These manifestations are vague and resemble those of dementia, hydrocephalus and disequilibrium syndrome. Thus, care must be taken at differential diagnosis. CT-scan has made it possible to diagnose early and treat appropriately. By observing the patient's progress through CT-scan one can determine whether operation is necessary or spontaneous healing can be expected. The most appropriate surgical procedure is burr hole, which carries a good prognosis. After operation, strict weight control should be observed during dialysis using Futhan which minimizes hemorrhage.

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The case of a 47-year-old male patient, receiving hemodialysis because of chronic glomeruronephritis, is reported. Acquired cystic kidney disease (ACKD) had already been diagnosed by routine abdominal imaging procedures, such as abdominal ultrasound or abdominal CT scanning. He complained of severe right-sided flank pain and was admitted to our hospital. Abdominal CT scanning and MRI revealed retroperitoneal hematoma caused by rupture of the cysts in the right kidney. The patient was managed conservatively and the hematoma disappeared completely. The pathogenesis and treatment of this rare condition is discussed.

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Peritonitis is one of the major complications of continuous ambulatory peritoneal dialysis (CAPD). We report a case of Campylobacter peritonitis in a patient on CAPD, which is very rare. Only 14 cases have previously been reported.
A 43-year-old woman, who had been treated with hemodialysis since 1970, started CAPD in 1985 because of obstruction of an arteriovenous fistula which was difficult to repair. Subsequently, she had often developed peritonitis. On July 5, 1991, she suffered from diarrhea with fever, and developed peritonitis after this episode. She was admitted to our hospital on July 8 since laboratory examination showed a CRP of 50.5mg/dl and 277 leukocytes/mm³ in the dialysate. The dialysate on admission was cultured and found to be positive for Campylobacter fetus. The patient, who reported an anaphylactic reaction to penicillins and cephalosporins, was treated with vancomycin, tobramycin and minocycline. Cultures later became negative for Campylobacter fetus, but positive for Enterococcus faecalis as a result of superinfection. A barium enema examination revealed a diverticulum in the ascending colon. She failed to respond to therapy because drug allergy prohibited appropriate antibiotic treatment. On August 21, as a result of persistent peritonitis evolving into sclerosing peritonitis, the Tenckhoff catheter was removed and hemodialysis was started with an intravenous catheter in the right subclavian vein. The peritonitis might have been caused by transmural migration through the intestinal wall after oral ingestion of Campylobacter fetus, although the route of infection is unknown.

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