On April 4, 1978, the first dialysis therapy in Japan for a leprosy patient with renal failure was performed in the dialysis unit of the National Leprosarium, Tama Zenshoen. Since then, during a 12 year 9 month period from April 1978 to the end of 1990, 22 leprosy patients have received dialysis therapy. of these, one had acute renal failure and 21 had chronic renal failure. These 21 cases were investigated with regard to their clinical course, causal disease, blood access, effects of drugs, effect of the therapy, complications, influence of the therapy on the clinical course of leprosy, and autopsy findings.
The results obtained were as follows: 1. Clinical course up to the onset of dialysis therapy was similar to that of usual patients with chronic renal failure. 2. Arterio and arteriolosclerotic nephrosclerosis, chronic proliferative glomerulonephritis, amyloidosis, interstitial nephritis, polycystic kidney, arteriosclerotic renal atrophy, and chronic pyelonephritis were recognized as causal diseases. These causal diseases were not leprosy-specific. Diabetic nephropathy was not found in any of the 21 patients. It seems that the incidence of diabetic nephropathy in leprosy patients is low. 3. Autogenous internal shunts prepared in these cases were used effectively, in some cases for many years. Problems such as closure, edema and low blood flow occurred, but not frequently. 4. Drugs used for usual patients with chronic renal failure, such as antihypertensive drugs (β-blockers, angiotensin-converting enzyme inhibitors and calcium channel blockers), inhibitor of urate biosynthesis, alfacalcidol and recombinant human erythropoietin, showed the expected effects when administered to leprosy patients with chronic renal failure. 5. Dialysis therapy had no influence on the clinical course of leprosy. Relapse did not occur even after many years of dialysis therapy. 6. Hemodialysis, 2-3 times a week 4-5 hours each time, was able to maintain patients in good condition for many years. 7. On autopsy, amyloid deposition in the kidney was detected often.

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The development of hemodialysis has enabled patients with end-stage renal disease to survive for a long time; consequently, ischemic heart disease has become an important risk factor in their mortality. Coronary artery bypass surgery, however, is still considered a high-risk procedure in these patients.
We examined the therapeutic results of percutaneous transluminal angioplasty (PTCA) performed between 1987 and 1992 in 12 patients with angina pectoris and end-stage renal failure who were on hemodialysis. They consisted of eight men and four women with a mean age of 56.3 years, and included five patients with diabetes mellitus, seven with hyperlipidemia, and eleven with hypertension. Two patients had a history of previous myocardial infarction. Angiographic success was obtained in 22 (82%) of 27 stenotic sites attempted and clinical success was obtained in 10 (83%) of the 12 patients. There was one in-hospital death from cerebellar hemorrhage. Angina recurred in 4 of the 10 patients after successful PTCA. Re-angiography was performed in 3 of these patients and restenosis was demonstrated. Repeat PTCA was performed successfully for all restenotic lesions.
Our findings show that PTCA in chronic hemodialysis patients is effective, and preferable to coronary artery bypass surgery.

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Inevitable accidents during physical training over on 11-year period were investigated in 111 chronic hemodialysis (HD) patients, and these data were compared with those for coronary heart disease (CHD) patients.
Exercise-induced hypotension was the most frequent accident (1.72%) in HD patients, the frequency being about 5.4 times higher than that in CHD patients. However, cardiac arrest or serious ventricular arrhythmia was not found in HD patients. Only chest pain was recognized with high frequency in CHD patients, whereas various symptoms were recognized with high frequency in HD patients.
According to these results, the authors conclude that effective countermeasures to exercise-induced hypotension should be developed for use during physical training in HD patients.

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As a method of managing blood pressure during hemodialysis (HD), we developed a pressure monitoring catheter which made it possible to preform continuous direct measurement of pressure within a shunt and a conducted preliminary study to determine whether or not this new catheter could be appled to the establisment of a new monitoring system of arterial blood pressure during HD.
The catheter was composed of two parts, i.e., a 12G double lumen catheter (Biocathera) for dialysis, modified by changing the connection site between the dialysis circuit and the pressure monitoring circuit to a Luer type, and a 21G elaster needle for pressure monitoring. The pressure monitoring catheter was protected by a catheter guard so that the pressure measuring point could be operated freely without contamination.
We found that pressures measured at the sites within the peripheral 1cm of the arterio-venous anastomosis were barely affected by the blood flow rate and were very similar to the blood pressure measured on the contralateral arm by the cuff method. However, pressures obtained from peripheral sites more than 2cm from the arterio-venous anastomosis fell with increasing distance.
The results of study suggest that the pressure inside the shunt obtained at sites within 1cm penipheral from the arterio-venous anastomosis most probably reflects the arterial pressure, and that a rapid decrease in blood pressure is recognizable in real time.
Complications arising from the catheter, including unsatisfactory blood flow, were not obsarved. This study suggests that the catheter is useful in a clinical setting for long-term monitoring of blood pressure during HD.

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Bacterial growth was examined in both 1.5% Dianeal^TM and peritoneal dialysis effluents (PDE) obtained from a 29-year-old female patient receiving CAPD treatment with Dianeal^TM. S. epidermidis and S. aureus were selected because they were the most frequently isolated microorganism causing CAPD-related peritonitis. Growth of bacteria was inhibited in the Dianeal^TM, but they persisted until the sixth hour and tended to increase in number until the twenty-fourth hour after inoculation. Although PDE is influenced by many factors affecting bacterial growth such as osmolarity, glucose, proteins, and pH, the most important factor enabling the bacteria to grow in the setting of PDE could not be identified. The fact that the bacteria did not increase in number until the 6th hour suggested that it is advisable to exchange CAPD fluid every six hours to prevent CAPD related peritonitis.

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The prevalences of two kinds of anti-hepatitis C virus (HCV) antibodies and HCV RNA were assessed in 30 patients undergoing hemodialysis. C100-3 antibody (HCV first generation antibody) was measured using an ELISA test (Ortho Diagnostics). A combination of antibodies against a core region and non-structural regions of the HCV genome (HCV second generation antibody) was measured by means of an EIA kit (Dainabot Corp.). HCV RNA (5'-noncoding region) was detected by a nested polymerase chain reaction (PCR).
C100-3 antibodies were positive in 10 (33%), second generation antibodies were positive in 18 (60%) and HCV RNAs were positive in 16 (53%) patients. Among 14 HCV RNA-negative patients, only three cases were anti-HCV-positive. The prevalence of each assay increased in accordance with the amount of transfusions, grade of liver injury and duration of hemodialysis. In all of the HCV RNA-positive cases, the cut-off indices of the second generation antibody were more than 90. Half of these cases were anti-C100-3-negative, and most of these patients maintained a normal transaminase level despite episodes of liver injury in the past. This indicated the presence of asymptomatic HCV carriers undergoing hemodialysis who had been missed by the screening using C100-3 antibody.
The prevalence of C100-3 antibody in the entire patient population of our hemodialysis unit was lower (13/57, 23%) than that determined in this study. Therefore, approximately one third of our hemodialysis patients were estimated to be HCV carriers. Based on the result confirming that second generation antibody and HCV RNA are closely related, the second generation antibody is assumed to be a useful assay for the screening of HCV carriers undergoing hemodialysis.

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Acquired cystic disease of the kidney (ACDK) is seen in patients on hemodialysis. The pathogenesis of ACDK, however, remains speculative. We performed an immunohistochemical study of insulin-like growth factor-I (IGF-I) in a patient with ACDK. Rabbit anti-human IGF-I antibody was applied to paraffin embedded kidney sections followed by avidin-biotin peroxidase complex. There was strong immunoreactivity to IGF-I in the lining cuboidal epithelial cells of cysts as well as in collecting ducts. However, we could not detect IGF-I immunostaining in the interstitium or vessels.
Since IGE-I has been shown to play an important role in hyperplasia or hypertrophy of the cells in an autocrine or paracrine fashion, the present results suggest that IGE-I might be involed in the pathogenesis of ACDK.

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The desferrioxamine (DFO) test and iliac bone biopsy were performed at the time of TPTX+AT. Amyloid (Am), aluminum (Al), and iron (Fe) deposits were studied in bone tissues by alkaline Congo red, Aluminon, and Berline blue staining, respectively. Various parameters of bone metabolism including serum levels of high sensitivity parathyroid hormone (HS-PTH), Bone Gla protein (OC), aluminum (Al), ferritin (Ft), and alkaline phosphatase (Alp) were determined simultaneously, and their relations with Am, Al, and Fe deposition were evaluated.
Al deposits were observed in 5 of 11 patients, and the preoperative DFO test was negative in 1 of these. Fe deposition and Am deposition were seen in 2 patients each. No correlations were observed between Am, Al, or Fe deposition and serum β₂-MG, Al, or Ft levels. The serum Alp level was within normal range in 8 of the 11 patients, but the serum OC level was significantly increased in all, suggesting the usefulness of this parameter in the diagnosis of secondary hyperparathyroidism.
These results suggest that it is important to examine the deposition of Am, Al and Fe in bone tissues before TPTX+AT.

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Recombinant human erythropoietin (rHuEpo) therapy is effective for renal anemia without iron deficiency in uremic patients while PTH has been suggested to be a uremic toxin on blood-producing organs. In this study, we investigated the effect of parathyroidectomy (PTX) on hematologic response to 14 months of rHuEpo therapy in two dialysis patients with refractory secondary hyperparathyroidism.
The entire rHuEpo treatment period was divided into 3 parts (pre-PTX, immediate post-PTX, post-PTX) based on hematocrit level (Ht), in both cases. The immediate post-PTX period was 48 days in case 1 and 30 days in case 2. ΔHt (%/100 days) and ΔHt (%/rHuEpo 1, 000U) were analyzed for each period. In case 1, ΔHt (%/100 days) was +0.48749 (pre-PTX), -5.7616 (immediate post-PTX) and +3.0336 (post-PTX: p<0.05 vs pre-PTX). Similarly, it was -3.5979 (pre-PTX), -0.87500 (immediate post-PTX), +2.0431 (post-PTX: p<0.02 vs pre-PTX) in case 2. ΔHt (%/rHuEpo 1, 000U) was also higher in the post-PTX period than in the other two periods in both cases. The difference between the value of ΔHt (%/rHuEpo) 1, 000U in the post-PTX period and that in the pre-PTX period, was +5.38%/1, 000U in case 1 and +12.10%/1, 000U in case 2. No iron deficiency was observed in either case.
We have demanstrated that elevated PTH is a hematologic inhibitor acting as a uremic toxin on blood-producing organs in dialysis patients. PTX may improve not only the uremic bone disease but also the hematologic response to rHuEpo therapy for renal anemia.

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Long-term prognosis after the start of hemodialysis and factors affecting prognosis were evaluated in patients undergoing hemodialysis at Yokohama Heiwa Hospital.
Subjects were 142 patients (82 male, 60 female) who started hemodialysis at Yokohama Heiwa Hospital from 1971 to 1990. Prognosis was analyzed by Kaplan-Meier's life-table analysis. The Impacts of diabetic nephropathy, sex, status at initiation of hemodialysis (age, calendar year, and with or without overhydration) on prognosis were assessed by univariate and multivariate analysis (Cox proportional hazard model).
Average age at the start of hemodialysis increased from 35yr to 60yr during the 20 years. The proportion of diabetic nephropathy cases increased remarkably. Univariate analysis showed a poor prognosis for diabetic nephropathy cases, males, abvanced age at the start of hemodialysis, those with overhydration, and with a recent calendar year start (after 1983). Multivariate analysis showed a significantly poorer prognosis with advanced at the start of hemodialysis, and overhydration, but not in association with diabetic nephropathy, sex, or calendar year at the start of hemodialysis. During the follow-up period, 71 patients died, and 31 of these (44%) deaths were attributable to cardio-vascular disease.

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A computer program designed to perform three-point Variable Volume Single Pool Modeling as described by Sargent JA and Gotch FA was developed. The normalized protein catabolic rate is independent of the amount of K·t/V urea in stable out patients receiving hemodialysis. The predicted predialysis plasma urea nitrogen level on the first dialysis of the next week was decreased in proportion to increasing K·t/V.

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To gain new insights into the clinical efficacy and safety of intravenously administered (i.v.) diltiazem-hydrochloride in hemodialysis (HD)-associated hypertension, a comparative study between i.v. diltiazem and sublingually administered (s.l.) nifedipine was performed in patients on HD.
In diabetic chronically hemodialyzed patients who have frequent episodes of emergent hypertension during HD, diltiazem 10mg i.v. significantly lowered blood pressure from 225±20/106±12mmHg to 163±32/84±12mmHg, n=28 p<0.001. Nifedipine 10mg s.l. also reduced blood pressure from 230±14/110±12mmHg to 140±28/90±25mmHg, n=22 p<0.001. The magnitude of the fall in blood pressure was greater with nifedipine than with diltiazem (fall in systolic: 66.1±8.0mmHg for the diltiazem treated vs. 90.2±21.2mmHg for the nifedipine treated, p<0.001). Furthermore, the effect lasted longer in patients given nifedipine than in those given diltiazem (70±14min for the nifedipine treated vs. 43±16min for the diltiazem treated, p<0.001). No major side effects were noted in either group except for a transient bradycardia in one patient given diltiazem.
It is concluded that both diltiazem i.v. and nifedipine s.l. can be safely used and are effective in reducing elevated blood pressure during HD in chronically dialyzed patients. Compared to nifedipine s.l., the relatively mild antihypertensive effect attained by diltiazem i.v. may be beneficial for preventing HD patients from cardiovascular events possibly induced by an abrupt drop in blood pressure.

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We studied the effects of various dialyzers, in particular the effects of the physical factors of high performance membranes (HPMs), on reduction of residual blood volume in the dialyzer.
Seven dialyzers, each of which had a different type of membrane and a different ultrafiltration rate (UFR), were examined in six stable maintenance hemodialysis patients, without changes in anticoagulation method. These patients had frequent episodes of thrombosis in the dialyzer during conventional hemodialysis (using low UFR dialyzers; Cuprophane (CUP), or Polymethylmetacrylate (PMMA)).
The residual blood volume in the dialyzer was significantly reduced with HPMs (Polysulfone (PS) and Polyacrylonitrile (PAN)). The residual blood volume was reduced in HPMs of PMMA, even when diabetic patients were excluded. Although the reduction of residual blood volume was due to membrane biocompatibility, other factors need to be considered as well.
In our study, reduction of residual blood volume was detected with CUP membrane of the high UFR type, which is considered to have less biocompatibility.
To decrease back filtration with HPM, the blood flow was poroportionately modified in parallel to dialysate flow with the high UFR dialyzer, PMMA.
The residual blood volume was increased more with the parallel flow dialyzers than with the counter flow dialyzers.
These results indicate that the physical factors of low transmembrane pressure and backfiltration are effective in reducing residual blood volume in dialyzers.
We suggest that not only certain anticoagulation methods, but also dialyzers with HPM, are effective in reducing residual blood volume in dialyzers.

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A 61-year-old woman with hypertension had received hemodialysis three times a week for four years and six-months without adequate water control. When the hemodialysis was started, she was found by CT scan to have slight calcification of the abdominal aorta.
The patient experienced severe back pain on Novemver 17, 1990. CT scan and aortogram revealed a DeBakey Type IIIb dissecting aneurysm and marked calcification of the abdominal aorta. About one hour after starting treatment to control her blood pressure, abdominal pain also appeared, but this was relieved by analgesics. She was continuously treated by hemodialysis with nafamostat mesilate as anticoagulant. The next day a serum amylase level of 2, 661IU/l was measured. Nafamostat mesilate, 40mg/day, was added. The patient's blood pressure was continuously controlled (systolic pressure 110-130mmHg), her abdominal pain was alleviated, and the serum amylase values returned to normal about two months later. The association between dissecting aneurysm and pancreatic injury in hemodialysis patients is discussed.

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We encountered a hemodialysis (HD) patient with severe hypoglycemia induced by disopyramide (DP). The patient had been administered 300mg of DP/day to control atrial fibrillation for the first time. However, the blood level of DP was below the therapeutic range (2-4μg/ml), so the dosage was increased to 600mg/day. Twenty days later, the patient suddenly fell into a hypoglycemic coma. We stopped DP and infused a high dose of 50% glucose. The patient had also been taking rifampicin (RFP) to treat a fever of unknown origin.
It is well known that DP is metabolized to mono-N-dealkyldisopyramide (MND) by cytochrome P-450 in the liver, and that RFP enhances this metabolism. Since DP and MND are both excreted in the urine, blood levels of DP and MND are increased in patients with renal failure. Therefore, if DP and RFP are administered together to an HD patient, a lower concentration of DP and a high MND level are to be expected, since RFP promotes the metabolism of DP to MND.
From a review of the literature, most cases of hypoglycemia induced by DP were observed in patients with normal liver function and impaired renal function. Blood levels of DP in 10 out of 13 cases were within the therapeutic range or lower.
Based on the foregoing, MND may well be the cause of hypoglycemia induced by DP.

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A 39-year-old female on chronic hemodiaiysis therapy since 1981 presented with tarry stool in 1985. Gastrofiberscopy and barium enema revealed no abnormal findings. In 1989 the patient presented with abdominal pain and tarry stool. Although gastrofiberscopy revealed no active bleeding in the stomach or duodenum, the massive gastrointestinal bleeding continued. Selective visceral angiography was performed, which disclosed active intestinal bleeding from the first branch of the superior mesenteric artery. Embolization with a stainless steel coil was performed to control the hemorrhage. Although embolization appeared to be effective, the patient underwent laparotomy because of the possibility of bowel necrosis or infarction. A small ulcer associated with an open-ended artery was noted in the jejunum about 1cm distal to Treitz's ligament, and local resection of the bleeding area was performed.
If endoscopy, upper gastrointestinal x-ray or barium enema are negative in a hemodialysis patient with massive gastrointestinal bleeding, selective intestinal arteriography and subsequent selective embolization are useful in diagnosing and controling the bleeding.

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A case of sudden cardiac arrest caused by intra-His bundle block with massive mitral annular calcification in a diabetic uremic patient is presented.
A 75-year-old male who had been undergoing hemodialysis for three years was admitted with a syncopal attack. His serial electrocardiograms taken once a month and Holter monitoring examined once a year had been interpreted as within normal limits since the beginning of hemodialysis. Although parathyroid hormone level had been within normal limits, the calcium-phosphorus product had often been more than 60, with a maximum value of 80. On admission he regained consciousness and the electrocardiogram showed a normal tracing. However, cardiac arrest occurred unexpectedly on the ward and continued despite artificial respiration and cardiac massage. The patient recovered consciousness and spontaneous respiration soon after an artificial pacemaker was implanted. According to subsequent electrophysiologic studies, although the His bundle electrocardiogram showed a splitting His wave without pacing, complete atrioventricular block was induced by 130beats/min atrial pacing and second degree atrioventricular block continued after the atrial pacing was turned off. With two-dimensional and Doppler echocardiography, massively calcified mitral annules and valve with a restricted opening were visible. A diagnosis of intra-His bundle block secondary to massive mitral annular calcification was established and a permanent pace maker was implanted.
This case, in which cardiac arrest was not predicted by frequent examination of serial electrocardiograms, strongly suggests the importance of electrophysiological studies in uremic patients with massive mitral annular calcification.

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It is said that hemodialysis is rarely acompanied by liver abscess. We report the case of a 76-year-old male on maintenance hemodialysis who was diagnosed as having multiple liver abcess. Although intravenous antibiotic treatment improved his symptoms, he showed an obstructive ileutic condition. Endoscopic examination revealed a tumor in, and completely obstructing, the transverse colon. Right hemicolectomy was performed. Histologically the tumor was an adenocarcinoma. The patient was discharged and is now being treated with maintenance hemodialysis. There has been no relapse to date.

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A 72-year-old male receiving CAPD who had a left nephrostomy is reported. His opposite kidney had previously been non-functional. Prior to induction this patient and his family selected to undertake CAPD treatment because of difficult alimentary control and a long commute from their home to our hospital, which would have been necessitated by periodic hemodialysis. The CAPD maintenance treatment extended over 55 months. During this period the patient continued to perform CAPD manipulations faithfully on a daily basis and performed his nephrostomy care and treatment two or three times a day.
Despite the fact that long term maintenance on CAPD therapy (even on hemodialysis) in elderly renal failure cases is difficult in general, this patient is a rare case who survived for a prolonged period while practicing the two aforementioned different procedures, simultaneously and patiently, by himself. It was thought that this good result was brought about because he not only had no physical complications, such as other systemic diseases but was also in an excellent state mentally.

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Three cases of acquired cystic disease of the kidney (ACDK) with renal cell carcinoma on long-term hemodialysis are presented; 47 and 46-year-old male patients and a 62-year-old female patient with complaints of lumbago, hematuria and right back pain, respectively. The duration of hemodialysis were 11 years 10 months, 15 years 7 months and 9 years 3 months respectively. Abdominal CT showed bilateral multiple renal cysts with renal enlargement in two cases and a shrunken appearance in one case. In all cases, multiple renal calcifications were present bilaterally but no solid masses were detected preoperatively. These patients were considered to be surgical candidates because of continuous and aggravated symptoms, the presence of renal calcifications on CT and their risk for the development of malignancy.
Bilateral nephrectomy with lymph node dissection was carried out through a transperitoneal approach in all cases. Histological examinations showed lesions of renal cell carcinoma in the two male patients bilaterally and only on the right side in the woman. None had developed metastasis.
In cases of ACDK undergoing long-term hemodialysis, it is important to periodically check for the development of tumorous lesions by abdominal CT and other methods. However, it is not always possilde to detect these lesions with preoperative examinations, as in our cases. Therefore, aggressive surgical treatment should be considered in ACDK cases on long-term hemodialysis showing aggravated symptoms such as lumbago and hematuria, and the presence of renal calcification on abdominal CT. Bilateral nephrectomy may be optimal.

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Successful pregnancy and successful parturition are still relatively rare occurrences in patients undergoing chronic hemodialysis (HD). So far, at least 34 such cases have been reported in Japan. This report describes two cases of successful delivery and the usefulness of measuring plasma α-human atrial natriuretic peptide (α-hANP) for determing dry weight (DW). Case 1. A 30-year-old woman had been undergoing HD since 1985. Recombinant erythropoietin (rEPO) therapy was continued so as to maintain hematocrit above 30%. She delivered a boy by caesarean section at 34 gestational weeks. His Apgar was 9 points, but body weight was only 1, 613g. α-hANP was measured at 29, 32 and 34 gestational weeks. Concentrations were 49.1, 37.7 and 34.4pg/ml, respectivery, and were markedly lower than those of normal pregnant women. Therefore, each DW was reset to ideal weight without complications for either the mother or the infant. Case 2. A 31-year-old woman had been undergoing HD since 1985. In 1987 she had undergone renal transplantation that failed after January, 1991. HD was restarted. She was given rEPO. α-hANP was above 100pg/ml between 25 and 30 gestational weeks. At 31 gestational weeks, when hematocrit increased from 27% to 33%, α-hANP was set to a suitable level, 59.9pg/ml. At 34 gestational weeks she delivered a boy by caesarean section. His Apgar was 8 points, but body weight was only 1, 713g. Recent remarkable progress in HD techniques and the use of rEPO, as well as good control on the part of patients with maintenance HD, has made successful pregnancy and delivery feosible. We measured α-hANP and the resetting of DW was achiered according to the results of α-hANP without complications for either the mother or the infant. As well as measuring the size of heart, α-hANP also seems to be useful in determining ideal weight for pregnant patients on maintenance HD.

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