The amount of dietary protein intake in hemodialysed patients was estimated two times, in 1987 and 1992, utilizing the urea kinetics model (UKM). The values obtained from UKM as well as nutritional assessment were also examined with regards to patient survival in order to determine whether these values are useful for predicting patient survival. The values calculated from records of dietary interviews (DPI) showed an excellent positive correlation with the protein catabolism rate (PCR) values assessed from the UKM study. Therefore, estimation of individual protein intake seems to be possible from the UKM study alone. The nutritional status and prognosis of patients were studied by dividing the patients into three groups; diabetic, elderly (more than 60 years old), and control. The two former groups showed worse survival than the control group and those who showed higher BUN/creatinine ratios, and lower serum albumin and poor anthropometries. The data measured in 1987 revealed that the patients with either a high BUN/creatinine ratio, more than 7.0, low serum albumin, less than 3.0g/dl, had poor survival during the 5 year follow-up period. Thus, these values seem to be hallmarks for predicting patient prognosis. The amount of protein intake was decreased in 1992 compared to that of 1987. This might reflect the good compliance of these patients with dietary guidelines, since the dieticians in our hospital are recommending restricted protein intake in order to prevent skeletal complications. Though the efficiency of hemodialysis evaluated by Kt/V analysis was optimal in the majority of patients, diabetic patients showed the worst value among the three groups. This suggests that revision of hemodialysis techniques is necessary for diabetic patients to achieve better results. Whether the amount of protein prescribed to patients, 1.1g/Kg/day, is enough is a question which must be resolved in the future.

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In order to clarify the effects of serine protease inhibitor FUT-175 on neutrophil activation by dialysis membranes, luminol-enhanced chemiluminescence (Lu-CL) after stimulation of dialysed polymorphonuclear neutrophils (PMN) by phorbol myristate acetate (PMA) was studied in 6 chronic hemodialysis (HD) patients. In HD with heparin (2, 000u+1, 000u/hr) as an anticoagulant, Lu-CL was increased to 132±13, 165±20% of the control after 15 and 60min of HD, respectively. On the other hand, Lu-CL remained unchanged with FUT-175 (50mg+40mg/hr), indicating that FUT-175 inhibited neutrophil activation by dialysis membranes during HD. The serum FUT-175 concentration at the inlet side of the dialyzer was maintained in a range of 10^-5-10^-6M. Furthermore, as a parameter of superoxide anion (O₂^-) production, Cypridina luciferin analog (CLA)-enhanced CL (CLA-CL) was measured after stimulation of PMN from 5 healthy volunteers with either PMA or formyl-Met-Leu-Phe (fMLP). CLA-CL did not change with the addition of FUT-175 (10^-4-10^-7M) after the stimulation with PMA, but after the stimulation with fMLP, CLA-CL was 24.5±13, 9.9±1.0kcpm with FUT-175 at concentrations of 10^-4 and 10^-5M, respectively, both of which were lower than in controls, 35.0±7.5kcpm. These results suggest that FUT-175 inhibits PMN activation by dialysis membranes during HD, and that this inhibitory effect is mediated not by the inhibition of protein kinase C, but by inhibiting the activation of an fMLP-sensitive receptor on PMN by dialysis membranes.

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Continuous ambulatory peritoneal dialysis (CAPD) patients obtain parenteral glucose continuously through aperitoneal membrane. This unphysiological state may aggravate atherosclerosis. The plasma lipid levels in 43 stable CAPD patients were measured and the effects of an HMG CoA reductase inhibitor (pravastatin) on plasma total cholesterol (TC) level were evaluated in 10 patients. The lipids in the 43 patients revealed levels of 206.6±40.4mg/dl for TC, 154.9±80.1mg/dl for triglyceride (TG) and 41.6±11.81mg/dl for HDL cholesterol (HDL). Plasma apoprotein levels were 114.4±19.3mg/dl for apoprotein AI (ApoA I), 23.76±4.88mg/dl for apoprotein A II (ApoA II), 109.97±22.5mg/dl for apoprotein B (ApoB), 3.33±2.26mg/dl for apoprotein C II (ApoC II), 13.6±5.54mg/dl for apoprotein C III (C III) and 5.41±1.83mg/dl for apoprotein E (ApoE). Both ApoB/ApoA I and (TC-HDL)/HDL (Atherogenic indices) were higher than in normal controls, 0.96 and 3.95, respectively.
Three months after pravastatin administration, TC and TG fell from 245.5±15.4mg/dl to 190.2±16.0mg/dl and from 206.5±51.3mg/dl to 181.1±64.8mg/dl (p<0.05), respectively. LDL fell from 170.9±20.3mg/dl to 114.3±20.4mg/dl (p<0.05). On the other hand, HDL increased from 33.3±5.7mg/dl to 40.4±10.2mg/dl (p<0.05) ApoA I and ApoA II from 116±17.7mg/dl to 121.6±16.0mg/dl and from 25.4±6.0mg/dl to 28.9±5.7mg/dl (p<0.05), respectively. ApoB markedly decreased from 125.6±12.5mg/dl to 110.6±14.3mg/dl (p<0.05). ApoC II and ApoE decreased slghtly from 4.71±1.6mg/dl to 4.31±1.68mg/dl and from 5.35±1.2mg/dl to 4.92±1.3mg/dl (p<0.05), respectively. No significant change in ApoC III was observed. The concentration and pharmacological kinetics of pravastatin in CAPD patients showed a delayed degradation time (T_1/2=2.8hrs). However the concentration at 24 hours after administration was less than 1.0ng/ml.
In conclusion, CAPD patients showed abnormal plasma lipid levels and pravastatin acts effectively to ameliorate abnormal lipid states in CAPD patients. Pravastatin might be used at the same dose as that of patients without renal failure.

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We have experienced blood line coagulation in blood delivery equipment five out of the 39 times we have used hemodialysis with FUT anticoagulation.
We therefore studied whether there were any clinical differences between patients who suffered blood line coagulation with FUT anticoagulation and those who did not. All patients studied were under hemodialysis treatment with FUT anticoagulation. With regard to the dialyzer membrane, the frequency of blood line coagulation was high with hemodialysis using a PAN (polyacrylonytrile) membrane. Clinical data showed that changes in hematocrit (Hct) during the two weeks before FUT dialysis were significantly higher in patients who suffered blood line coagulation than in patients who did not (p<0.05). There were no differences between the two groups in blood platelet counts, white blood cell counts. serum Ca concentrations or blood flow volumes.
These results suggest that in hemodialysis with FUT anticoagulation, the dosage of FUT must be increased in patients with a recent abrupt increase in Hct. In addition, an appropriate dialyzer membrane must be used to prevent blood line coagulation.

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Regional cerebral blood flow (rCBF) measurements using the ¹³³Xe gas inhalation method were performed in 8 chronic renal failure patients, 2 of whom had not yet started hemodialysis (HD) while the other 6 were already on HD. Total mean CBF value (TMV) was significantly elevated in the pre-HD patients (79.7±6.0ml/100g/min: p<0.001), but was significantly decreased in the patients who had already undergone sufficient HD (63.0±8.7ml/100g/min: p<0.005). TMV did not, however decrease in the 2 patients who received insufficient HD. Blood pressure, P_aCO₂ and CTR did not change significantly after, as compared to before, the introduction of hemodialysis, and these parameters did not correlate with TMV. Hemoglobin increased significantly after HD introduction in the sufficient HD group (p<0.05) and correlated with TMV (p<0.05). TMV, hemispheric mean CBF and the laterality index did not change significantly after, as compared to before, A-V shunt formation. Factors exerting influences on CBF are not well understood, but anemia may be the most important contributory factor in patients with chronic renal failure.

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In order to clarify the effect of a PEG grafted cellulose membrane dialyzer under conditions of reduced heparin dosage, a controlled cross-over study involving 8 chronic hemodialysis patients was conducted with an original cellulose membrane (SD membrane) and a PC membrane which had been grafted with PEG by 100 or 180ppm to the SD membrane for hemodialysis (HD).
After HD under normal heparin dosage (100%) and reduced heparin dosage to 80% and 60% of normal levels, conditions, the amounts of adsorbed protein, LDH, and other blood components deposited on membranes and residual blood in dialyzers were investigated.
The amounts of adsorbed protein and LDH seemed to be decreased according to increases in the grafted PEG and heparin dosage. Analysis of adsorbed proteins by the SDS-PAGE method showed different results with these membranes. The number of PC membrane protein bands observed was less than that of the SD membrane. The PC membrane (180ppm PEG) had the least blood component deposition, as compared with the SD membrane, on the basis of scanning electron microscopy (SEM).
However, it was not possible to demonstrate a significant relation between residual blood and the amount of the PEG graft.
Furthermore, the amount of adsorbed protein was investigated in terms of water removal rates. The effect of adsorbed protein on th water removal rate less with the PC membrane (180ppm) than with the SD membrane. Under conditions of reduced heparin (40% of normal dosage), the PC membrane clearly suppressed leukopenia.
These results indicate that the PC membrane has biocompatible characteristics such as leukopenia suppression and antithrombogenicity. The PC membrane was found to be remarkably useful for HD therapy with a reduced heparin dosage.

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To evaluate employment and rehabilitation problems faced by patients on maintenance hemodialysis, a questionnaire survey was carried out at the 7 organization facilities. Two hundred and eighty patients with CRF on maintenance HD whose ages ranged from 15 to 64 years, were examined to determine whether or not they could return to their jobs. Four different psychological tests (Y-G, CMI, SDS, MAS) were also conducted. One hundred and sixty six patients who returned to their jobs, were classified as the ‘Working group. Eighty seven patients did not return to their jobs. Among these cases, 16 patients had no desire to work again. Of these 16 patients, 15 who answered the four psychological tests completely, were especially notewarthy in this study (‘No job desire group’). Nineteen patients had the desire to work, but no appropriate jobs to which to return. For this reason, 15 of the 19 were classified as the ‘No job group’. First, the patients in the ‘No job desire group’ were compared with patients in the ‘Working group’ in terms of such social factors as sex, age, term of HD, school career and marrital status; these were speculated to be important factors in returning to their jobs. Secondly, the patients in the ‘No job desire group, and the ‘No job group’ were compared with each of the 30 patients matched and samplad from the ‘Working group with regards to the results of the four psychological tests.
The results demonstrated that the percentages of male and single patients in the ‘No job desire group’ were significantly larger than those of patients in the ‘Working group’. In addition the average term of HD was comparatively shorter. School career appeared to be another factor preventing patients from returning to their jobs. Additionally, patients in the ‘No job desire group’ were significantly more neurotic, depressive and anxious, compared with matched patients from the ‘working group’ with comparable social factors. The data presented here led us to conclude that, patients on maintenance HD who lack the desire to work again need social support and psychological care.

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The antihypertensive effects and pharmacokinetic properties of cilazapril, a long-acting angiotensin converting enzyme (ACE) inhibitor, were investigated in seven mildly hypertensive patients on maintenance hemodialysis (HD). A single dose (0.5mg) of cilazapril was administered orally, and plasma levels of cilazapril, cilazaprilat, an active diacid form of cilazapril, plasma renin activity, angiotensin I and II concentrations and serum ACE activity were measured on a day with HD and On a day without HD. Cilazapril reduced both systolic and diastolic blood pressure to normotensive levels. Serum ACE activity was markedly suppressed over 24hr. There were no significant changes in plasma renin activity and either angiotensin I or II concentrations after administration of 0.5mg cilazapril. Thus, the hypotensive effects of cilazapril may be due to inhibition of the tissue renin angiotensin system rather than of the circulatory system. On a day without HD, the maximum concentration (Cmax) and time required to reach the maximum concentration (Tmax) of cilazaprilat were 21.4ng/ml and 18.3h, respectively. On a day with HD, the Cmax and Tmax of cilazaprilat were 14.0ng/ml and 11.2h, respectively. The half-life of cilazaprilat was 28.6h without HD, and 3.4h during HD. These data suggest that the drug was partially removed by HD. A simulation, calculated on the basis of the above pharmacokinetic parameters, indicates that the recommended daily dose of cilazapril could be 0.5mg for hypertensive patients on whom hemodialysis is performed every other day.

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Forty-four bridge fistulas using E-PTFE grafts including 18 of loop grafts and 26 of straight grafts were implanted in 39 chronic hemodialysis patients over a seven year period from 1985 to 1991. Overall graft patency rates at one, two and three years were 52.2±7.8%, 42.9±8.1%, and 31.3±9.2%, respectively, with no significant differences between the two groups. This poor result was thought to be due to the higher morbidity rate (16/44, 36.4%) less than one year after creation of the bridge fistulas. These patients were aged and/or diabetic, or critically ill. The frequency of salvage operation was higher in the former (22 times) than in the latter (16 times). Although salvaged grafts resulted in a prolonged graft patency period in both groups, it was without statistical significance as compared to non-salvaged grafts. The majority of salvage operations were performed because of thrombosis or poor blood flow in the bridge fistulas (31/38, 81.6%), and the main cause of thrombosis or poor blood flow was venous outflow stenosis (VOS, 25/31, 80.6%). Thrombectomy alone with a Fogarty catheter was performed more frequently in the former but revision was more frequently needed in the latter. Revision was mainly carried out because of VOS (14/16, 87.5%). The arterial side in our bridge grafts had far fewer problems.
Salvage operation was capable of producing prolonged graft survival, and is therefore the optimal method available.

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Hyperphosphatemia in chronic dialysis patients cannot be coped with by medicinal treatment alone. In recent years, low-phosphate foods as an adjunct to diet therapy have been the focus of attention. The study presented here is a multicenter clinical evaluation of low-phosphate noodles. Studies were carried out at 5 institutions nationwide Twouty-one maintenance dialysis patients, who had serum phosphorus levels of 4mg/dl or more and were admitted for accurate monitoring and control of their daily meals, were studied. Among them, 4 had not received any phosphorus-bound compounds. The 21 patients were given 14 packs of low-phosphate noodles, with instructions to consume them all within 4 weeks, taking one pack daily or one pack every other day. Their serum levels of Ca, P, Na, and K were determined before and after ingestion of the low-phosphate noodles, and an investigation to compare daily nutrient intakes before and during ingestion of the low-phosphate noodles was carried out along with a questionnaire survey. The mean serum level of phosphorus declined from 6.1±1.5mg/dl to 4.7±1.2mg/dl (p<0.01) but rose to 5.7±1.3mg/dl 5 weeks later. Serum levels of Ca on the whole remained unchanged, but rose from 4.8±0.2mEq/l to 5.1±0.1mEg/l (p<0.01) in 4 patients not exposed to any phosphorus-bound compound.
Serum Na levels remained unchanged, while serum K levels declined slightly. The comparison of nutritient intakes showed that P was decreased by about 167mg/day on the average and that K was also slightly decreased. Salt levels were moderately increased, but the change was not large enough to produce weight gain. About 80% of patients satisfactorily took 3/4 or more of the low-phtsphate noodles.
According to the questionnaire results, 19% of patients answered that the low-phosphate noodles were palatable, and about 80% of patients gave a favorable answer when responses such as “not too bad” were taken into account. Based on the results presented here, the low-phosphate noodles seem to be a useful adjunct to diet therapy for prevention of hyperphosphatemia in chronic dialysis patients.

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The pharmacokinetics of Isepamicin Sulfate (ISP), which is excreted mainly by the kidney, were investigated in patients undergoing HD and CAPD. Intravenous administration of ISP at a dose of 200mg was carried out in 7 patients on HD and 5 patients on CAPD. Serum concentrations of ISP were measured by fluorescence polarization immunoassay (FPLA). The two compartment model was used for pharmacokinetic analysis. Hemodialysis patients had an elimination half life (T_1/2β) of 53.48±14.2 hours when they were not on HD and 2.48±0.61 hours during HD. CAPD patients had an elimination half of 40.67±7.58 hours. The whole blood clearances of ISP by HD and CAPD were 95.4±30.6ml/min and 2.56±0.97ml/min, respectively.
In conclusion, ISP excretion was remarkably prolonged in patients with chronic renal failure. This drug can be effectively removed by HD, however, necessitating supplementation after each dialysis session. Removal during CAPD was negligible. Drug monitoring is recommended for safe and effective treatment in chronic renal failure patients on all dialysis modalities.

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In order to clarify the efficiency of combination treatment with dimethyl sulfoxide (DMSO) and plasma exchange, we compared the effects of combination treatment versus other conventional treatments in eleven patients with systemic amyloidosis. The combination treatment was carried out on one patient with primary amyloidosis and 3 with secondary amyloidosis. Plasma exchange was usually carried out by the single filtration method because it has been assumed that amyloid proteins show remarkable diversity in molecular size, and 5-10ml of DMSO was given percutaneously on the day before the plasma exchange therapy. Since amyloid deposition was already extensive in most cases at the start of therapy, among the 4 patients receiving the combination treatment 3 died within 1 year of admission. Mortality among the patients receiving other conventional treatments was also high, and the overall mortality of the 11 patients was 64 percent. Thus, it appeared that there were no differences in either survival or disease progression between these two groups. However, we found that the combination treatment delayed amyloid deposition and renal impairment in two patients.
We suggest, therefore, that the lifespan of a patient might be prolonged by this treatment which combines DMSO and plasma exchange, if initiated at an early stage of systemic amyloidosis.

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In our basic investigation, endotoxin did nat pass through a polysulfone membrane, and almost all endotoxins were absorbed at the outer membrane surface. Based on these results, utilizing a polysulfone membrane concentrator with external ascites perfusion was performed to decrease the level of endotoxin contained in processed ascites. The concentration of endotoxin in the processed ascites was markedly decreased with the new system (30.4pg/ml) as compared with the conventional system (8, 480pg/ml). Body temperture was not elevated after the infusion of processed ascites. No changes in laboratory findings were observed. This new mothod, which utilizes a polysulfone membrane concentrator with external ascites perfusion, may be an excellent means of removing endotoxin.

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We examined serum cardiac myosin light chain 1 [MLCI], serum creatine kinase [CK], lactate dehydrogenase [LDH], and serum myoglobin levels in 10 patients with heart disease, and in 12 patients without heart disease on maintenance hemodialysis [HD] before and after HD.
The MLCI level of HD patients was not decreased after HD, suggesting that MLCI was not dialyzed. Furthermore, there was no significant difference in MLCI level between patients with and without heart disease. The MLCI level was positively correlated with myoglobin level in every HD patient.
These data suggest that in HD patients the MLCI level is not useful in assessing cardiac involvement or damage due to HD, since MLCI in these patients may reflect skeletal muscle myosin light chain.

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A brain abscess which developed in a hemodialysis patient was successfully treated without surgical intervention. A 68-year-old man with a two-year history of hemodialysis was admitted to our hospital because of high fever and headache. On admission, nuchal rigidity and double vision were noted.
Leucocytosis was absent in peripheral blood and CRP was negative. Cerebrospinal fluid demonstrated a significant increase in polymorphonuclear cells and a low glucose level suggesting bacterial meningitis. An antibiotic, cefotaxime (CTX), was thus administered. Intially CTX treatment resulted in temporary improvement, but several days later his clinical condition and CSF findings worsened. CT scans of the head revealed a low absorptive region of 3cm in diamiter with marginal enhancement in the left posterior lobe, suggesting a diagnosis of brain abscess. Drainage of the abscess was contemplated, he was thought to be a high risk candidate because of his serious complications. We decided to treat him conservatively by changing the antibiotic to imipenem. Treatment for 6 weeks resulted in resolution of the brain abscess. To date, 12 months after discontinuation of the antibiotics, there is no evidence of recurrence of the brain abscess. We feel that in treating brain abscess in a hemodialysis patient, non operative management should be initiated first with weekly follow up by CT scanning, and if there is no improvement in a few weeks, surgical intervention should be performed.

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We report the case of a CAPD patient who developed organizing pneumonia. A 64-year-old male developed renal failure due to proliferative glomerulonephritis. CAPD was started in April 1987. A violent fit of coughing occurred in January 1990. Chest X-ray films showed infiltrates of the right middle and lower lung fields. He was treated with ciprofloxacin hydrochloride 300mg/day for a diagnosis of pneumonia and bronchitis. The cough improved in several days, but the abnormal shadow did not completely disappear. In January 1990, he was admitted to Hiroshima University Hospital for a complete medical examination. Physical examination at the time of admission revealed moist rales over the right lung field and mild edema in both lower extremities. Laboratory findings at the time of admission: white blood cell count, 5, 800/mm³; sedimentation rate, 160mm in 1 hour; CRP, 3.0mg/dl. Transbronchial lung biopsy was performed and pathologic findings included thickening of alveolar walls by fibrosis and some alveoli filled with immature fibroblasts. Based on these findings we diagnosed organizing pneumonia. He was treated with prednisolone 20mg/day and the abnormal shadow disappeared. If an abnormal shadow on chest X-ray films does not improve with antibiotic treatment in a CAPD patient, the diagnosis of organizing pneumonia should be considered.

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Bilateral renal-artery embalizatian (RAE) was performed on a 42-year-old male nephrotic patient with liver cirrhosis and diabetes mellitus. Open renal biopsy revealed membranous glomerulonephritis with diabetic nephropathy. RAE was performed twice. He died the day after the second RAE. Many thrombi were observed in the vessels around the adrenal gland and the renal artery on autopsy. It was suggested that infection from the open biopsy wound had caused disseminated intravascular coagulation.

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A 14-year-old girl with end-stage renal failure due to chronic glomerulonephritis was started on CAPD in February, 1991. After 6 months she presented with cough and mild dyspnea and was admitted to Jichi Medical School hospital. A chest X-ray revealed right pleural effusion. Pleuroperitoneal communication was diagnosed by the presence of a high glucose concentration in pleural fluid, compared with her blood, and was confirmed by ^99mTcHSA peritoneography. Pleurodesis with 40ml of autologaus blood was performed, combined with the use of a reduced exchange volume of CAPD fluid. After three weeks, CAPD at the regular volume was initiated without recurrence of hydrothorax. Furthermore, only transient low grade fever and slight chest pain were observed as a side effect. Pleurodesis with autologous blood may be useful in the treatment of pleuroperitoneal communication in a CAPD patient.

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The case of a 58-year-old man with acute renal failure, rhabdomyolysis and ischemic colitis induced by mamushi viper venom is reported. On admission, abnormal elevations of BUN, serum creatinine, LDH and CPK levels were noted. We suspected ARF due to rhabdomyolysis and therefore started treatment with hemodialysis. Renal biopsy showed more severe pathological findings than those typically seen in ARF; these were mesangiolysis and patchy renal cortical necrosis. Further examination revealed the coexistence of ischemic colitis. The development of renal injury (mesangiolysis and cortical necrosis) and ischemic colitis seemed to have resulted from a circulatory disturbance induced by the snake venom. Our case shows the importance of paying attention to systemic symptoms related to this circulatory disturbance as well as the local compartment syndrome affecting the bitten site, in treating patients suffering from mamushi viper venom.

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Chilaiditi's syndrome is a state of bowel interposition between the diaphragm and the liver. It can happen as aresult of megacolon, diaphragmatic paralysis, liver cirrhosis and certain other factors. However, it is very uncommon in patients undergoing peritoneal dialysis.
We report a 69-year-old female who was followed in our urology department for bilateral multiple urinary tractstones and had a nephrostomy in 1971. However renal function steadily deteriorated due to obstructive uropathy. ln 1981, she developed chronic renal failure requiving dialysis therapy. A Tenckoff Catheter was inserted and intermittent peritoneal dialysis (iPD) was initiated. About ten years passed without major difficulties. Then iPD had to be discontinued because of fungal peritonitis So she was switched to hemodialysis.
After 6 months, she complained of chest discomfort and an X-ray demonstrated right diaphragm elevation and CT showed interposition of bowel between the right diaphragm and the liver. Chilaiditi's syndrome was diagnosed.
In this case, long-term iPD in the supine position could be one cause of Chilaiditi's syndrome.

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A patient undergoing chronic dialysis, because of diabetic nephrpathy, with intractable ascites was successfuly treated with the extracorporeal ultrafiltration method of ascites (EUA). A 74-year-old woman who developed renal dysfunction due to diabetic nephropathy had massive ascites resistant to diuretics and albumin infusion, and was obliged to undergo simple paracentesis, Subsequently, she was transferred to our hospital, where hemodialysis therapy was initiated. Her ascites was not reduced by either hemodialysis or the extracorporeal ultrafiltration method (ECUM) because of hypotension during these procedures. We could not obtain sufficient clinical effects with reinfusian of cell-free and concentrated ascitic fluid. Therefore, we applied EUA with regular hemodialysis. As EUA remarkably decreased the amount of ascites, she was able to leave hospital. It was concluded that EUA will be of benefit in managing intractable ascites.

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