Questionnaires were sent to 2, 283 dialysis units in February 1992, to determine the present states of renal cell carcinoma in chronic hemodialysis patients. The response rate was 64.1%. Renal cell carcinomas were detected in 184 dialysis patients between March 1990 and February 1992. The age of the 184 patients (150 males and 34 females) was 53.8±11.8 (mean±SD) years, and the mean duration of dialysis was 111.0±64.6 months. The clinical diagnosis was based on sonographic examination (93 cases) and CT scan (71 cases). Only 14 of these patients were symptomatic. The original kidney disease was chronic glomerulonephritis in 146 cases. Acquired renal cystic disease was found in 141 out of 178 renal cell carcinoma patients (79.2%). Curative nephrectomy was performed in 124 out of 182 patients. The mean tumor diameter was 4.7±3.2cm. The 153 cases with renal cell carcinoma were histologically confirmed. The 19 out of 182 patients had metastasis. The 141 with acquired renal cystic disease had a longer duration of dialysis (122.2±62.4 months) than the 37 without acquired renal cystic disease (67.2±53.2 months). However, in this study, the metastatic rate with acquired renal cystic disease was not lower than that without acquired cystic disease. In conclusion, 184 renal cell carcinomas were found during the two years preceding this report and the prevalence was the highest documented in the five most recent questionnaires.

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One of the most important determinants of high performance dialysis is the status of blood access (A-V shunt). In this study, we assessed the functional status of A-V shunts by two methods, shunt blood flow volume (Q_B) by the pulse doppler method and determination of fractional recirculation (R) based on the blood urea nitrogen value and serum level of creatinine. The subjects included 32 patients on maintenance hemodialysis. The blood flow rate in the brachial artery was 55.0-576.0ml/min (303.0±152.1ml/min) on the shunt side and 28.3-235.0ml/min (67.7±44.6ml/min) on the opposite side. Q_B, which was calculated mathematically by deducting from the two measurements, was 15.4-466.2ml/min (238.5±137.8ml/min). In addition, a comparative study of Q_B was done in two patient subgroups according to R values. Q_B in the patient subgroup having an R value greater than 0.15 was significantly lower than that in patients with R values below 0.15, i.e. 91.6±42.8ml/min vs. 259.4±133.9ml/min, respectively (p<0.02). Moreover, a significant negative correlation between Q_B and the R value (r=-0.658, p<0.001) was found. Based on those results, we conclude that the determination of R value is useful for evaluating A-V shunts from a practical viewpoint, which is assumed to be essential for achieving high performance dialysis.

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Membrane materials interact differently with blood. In the present report, adsorption of blood components (proteins and cells) on hydrophilic polyvinyl alcohol (PVA) and nonhydrophilic polysulfon (PS) filters were investigated. Proteins and cells were detected by scanning electron microscopy and the amounts of adsorbed proteins were analyzed by SDS-PAGE methods. The following results were obtained.
1. Blood components were slightly adsorbed on the PVA filter. The structure of the inner wall of the filter was well preserved. On the other hand, large quantities of blood components were seen on the PS filter, and the inner wall structure was barely recognizable.
2. When the amount of adsorbed albumin on the PVA filter was fixed at 1.0, the amount of adsorbed proteins on this filter was calculated to be 2.0-2.5, the sum of proteins such as albumin (1.0), IgG (0.6-0.8), fibrin (0.1-0.2) and erythrocytic proteins (0.5-0.7). The amount of adsorbed protein on the PS filter, calculated to be 4.0-4.5, was the sum of proteins such as albumin (1.2-1.5), IgG (0.8-1.1), fibrin (0.4-0.5) and erythrocytic proteins (0.9-1.1). In conculusion, these results may contribute to understanding the anti-thrombogenecity of PVA filters.

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The ultrasonographically determined diameter of the inferior vena cava (IVC) correlates with circulating blood volume, central venous pressure and plasma atrial natriuretic peptide level. Therefore, IVC is a good parameter of body fluid volume in hemodialysis (HD) patients. Since right-side cardiac overload could alter this correlation, we studied IVC diameter during HD in a uremic patient with pericardial effusion (PE). In stable chronic HD patients without PE, the mean maximal IVC diameter during quiet expiration (IVCe) and the minimal diameter during quiet inspiration (IVCi) decreased in parallel with the removal of body fluid during HD and became 7.2±0.2mm and 0.1±0.1mm, respectively, at the end of HD (mean±SE). On the other hand, as the amount of PE increased, IVCe and IVCi were greater at the end of HD. In three patients with massive PE, IVCe was more than 20mm and did not change even with the induction of hypovolemic hypotension by water removal. These results suggest that IVCe does not correlate with the amount of body fuid in the presence of massive PE. We conclude that the degree of PE should be examined in measuring IVC diameter as a marker of body fluid volume in HD patients.

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From November 1986 to March 1991, a total of 29 patients (16 males and 13 females) with secondary hyperparathyroidism were surgically treated by means of total parathyroidectomy with autotransplantation into the forearm. We performed modified neck dissection and resection of the bilateral thymic tongues with parathyroidectomy in all cases in order to prevent persistent hyperparathyroidism and recurrence due to ectopic glands. Among these cases, there were 3 (10.3%) in whom resected lymph nodes and thymic tongues showed metastasis of thyroid carcinoma on pathological examination, and minimal thyroid carcinomas were found in 2 cases who subsequently underwent thyroid lobectomy. The remaining case was followed clinically until the carcinoma became manifest.
Therefore, we recommend this operative method for secondary hyperparathyroidism, and subsequent thyroid lobectomy in cases with positive lymph nodes or thymic metastasis.

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This study was conducted to assess how peritoneal permeability and lymphatic absorption contribute to ultrafiltration insufficiency (UFI) in CAPD patients. The transcapillary ultrafiltration volume (TCUFV) and the lymphatic absorption volume (LAV) were measured using dextran 70 as well as the dialysate/plasma (D/P) creatinine ratio and albumin excretion at the time of peritoneal equilibration test (2-liter dialysate with 1.88% dextrose) in 30 CAPD patients. Seven patients demonstrated UFI (UF volume<300ml/day), of whom 3 showed low TCUF with high peritoneal membrane permeability, 3 had high LAV with normal membrane permeability and 1 had low TCUFV and high lymphatic absorption. Mean values of TCUFV, the lymphatic absorption volume and creatinine clearance in the 30 patients were 2.1, 1.7 and 5.1ml/min, respectively. There was a significant positive linear correlation between TCUFV and the lymphatic absorption volume (r=0.798). Patients with UFI showed relatively elevated lymphatic absorption volumes compared to their TCUFV, which were considered to have contributed to UFI. There was a weak positive correlation between TCUFV and the D/P creatinine ratio and a negative relation between the lymphatic absorption volume and albumin excretion. TCUF and lymphatic absorption showed no significant relations to body weight, age, duration of CAPD therapy or episodes of peritonitis. Increased lymphatic absorption is therefore speculated to be a major cause of UFI, in addition to a highly permeable membrane, in CAPD patients.

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Anticoagulant free hemodialysis (HD), without complications, was possible with selection of an antithrombogenic membrane material and improvement of HD lines.
We performed anticoagulant free HD in 6 long-term maintenance HD patients and assessed changes in various parameters involved in the coagulation-fibrinolysis system. Based on the results, the antithrombogenic properties of various membrane materials were evaluated.
Although the thrombin-antithrombin III complex (TAT) values were not significantly changed during HD with heparin, they rose significantly, by 9.1 fold, during anticoagulant free HD as compared to HD with heparin.
Among the various HD membranes compared, polyethylene glycol grafted cellulose (PC) membrane was rated superior in terms of antithrombogenicity, since the changes in TAT, percent decrease in platelet counts and PF-4 were smaller, and no residual blood was observed after HD.

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The incidence of intracerebral hemorrhage in chronic hemodialysis patients is high.
We studied hematoma location and size and clinical outcomes in 10 patients who had received hemodialysis treatments at Kyoto Minami Hospital. In addition, we reviewed hematoma location and clinical outcomes in 45 hemodialysis patients from the literature.
Hematoma location in hemodialysis patients is similar to that in non-hemodialysis patients with regard to incidence. The hemorrhage was in the basal ganglia in 71 per cent, was subcortical in 18 per cent, and was within the posterior fossa in 11 per cent.
Prognosis was poor. The motality rate was 63%. In particular, the prognosis was found to be death in patients with coma.
When intracerebral hemorrhage occurs in a hemodialysis patient, the hematoma is apt to be large. However, absorption of the hematoma may be good, such that surgical removal of the hematoma can be performed when indicated.

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Low molecular weight heparin (LMH) is a relatively new drug, fractionated from conventional unfractionated heparin, which has potential advantages over heparin for clinical use. Several problems should be resolved in applying LMH in hemodialysis; the need for bed side monitoring, neutralization by protamine, differences in pharmacological activity between products, pharmacological activities other than coagulation and long-term safety and side effects. We have identified a new parameter of blood coagulation with LMH, so called Xa activated coagulation time (XaACT), which involves a modified method of determining the blood coagulation time activated by celite and factor Xa, using hemocron method. It was found, in the present study, that XaACT had a better correlation with anti-Xa activity than did ACT and APTT either in vitro or in vivo during hemodialysis. With regard to changes in coagulation time during hemodialysis with LMH, ACT and APTT were not prolonged, as expected, but anti-Xa activity and XaACT were significantly prolonged during dialysis. XaACT is thought to be a useful blood coagulation parameter of LMH in hemodialysis. Protamine has the effect of neutralizing heparin, but there have been no reports to date on neutralization of LMH by protamine during hemodialysis. We studied the effect of protamine on LMH in terms of Xa activity, XaACT, APTT and ACT. APTT and ACT were completely neutralized, to pretreatment levels, by protamine. Otherwise XaACT and Xa activity were inhibited 30-50% by protamine. We think that there is only a slight risk of bleeding in LMH neutralization by protamine because anti-IIa activity is completely neutralized and ACT is normalized to the pre-treatment level.

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In order to clarify the interaction between cytokines (CK) and hemodialysis (HD), the effect of membrane characteristics on cytokine production by mononuclear cells (MNC) was examined by randomized crossover trial.
Eighteen HD patients were randomly divided into 3 groups, and the first group underwent HD with low-flux (L) cellulose (C) for 2 weeks, high-flux (H) C for the next 2 weeks, and L polymethylmethacrylate (P) membranes for the last 2 weeks. In the second group, HD membranes were changed from LC to LP and then HP for each 2 week interval. The third group underwent HD with a constant membrane for 6 weeks. Endotoxin levels in dialysate remained below 10pg/ml and HD conditions other than the HD membrane were unchanged throughout the study period. MNC separated from the blood taken at the end of each 2 week period, before, 30min after starting and at end of HD, were cultured with or without lipopolysaccharide (LPS) for 18hrs, then the supernatant concentrations of TNFα, IL-1β, and IL-6 were measured by the ELISA method.
No significant differences were observed in either LPS stimulated or nonstimulated CK levels before HD among these membranes. The LPS stimulated TNFα level at 30min after starting HD was significantly decreased but no differences were observed among membranes. IL-1β and IL-6 levels on the C membrane were significantly decreased at 30min after starting HD in the LPS or nonstimulated conditions, whereas on the P membrane, these decreases were observed only with LPS stimulation. TNFα, IL-1β, and IL-6 levels had recovered to pre-HD values by the end of HD.
These results suggest that transient decreases in CK production during HD are greater with C than with P membranes, but the characteristics of HD membranes exert minimal effects on CK production by MNC, at least at the treatment durations examined in this study.

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There is currently a 5% CAPD population in Japan, with annual increases expected. CAPD is viable for most ESRDs, but patients having undergone prior abdominal surgery are considered questionable candidates. Adhesions in the peritoneum may prohibit the patient from being adequately dialyzed and may also complicate proper catheter insertion. In our unit, we have never experienced a case in which this criterion prevented a patient from selecting CAPD as means a therapy.
Among 74 CAPD patients in our unit, 19 had a history of prior abdominal surgery while 55 did not. Both groups had catheters inserted into the Douglas' cavity successfully. Two of the 19 prior abdominal surgery patients and 5 of the 55 from the latter group had to undergo catheter reinsertion. This was due to in/outflow obstruction. Other catheter displacements unrelated to solution flow obstruction, and not requiring catheter reinsertion, were as follows: 2 of the 19 from the former and 19 of the 55 non-abdominal surgery patients group. Differences in data from the respective groups were not considered significant. Nether catheter displacement nor the type of catheter used had any great impact on the findings. Urea and daily UF level and average glucose concentration in the solution used did not differ significantly between the 2 groups over a 3 month period.
Although outcomes from prior abdominal surgery are variable, it does not necessarily preclude CAPD catheter insertion.

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The serum level of hyaluronic acid (HA), a high molecular weight glycosaminoglycan of the connective tissue matrix, has been proposed as a marker of dialysis related amyloidosis. To certify this proposal, we investigated the correlation between serum HA and synovial thickness of the hip joint in 26 patients on maintenance hemodialysis. Serum HA was measured by a sandwich protein-binding assay. Synovial thickness of the hip joint was determined by ultrasonography and was expressed as the head capsular distance (HCD) and neck capsular distance (NCD). Serum HA, HCD and NCD correlated positively with the duration of hemodialysis (r_s=0.50, p<0.01; 0.72, p<0.01; 0.73, p<0.01). Serum levels of HA were significantly higher in patients with carpal tunnel syndrome (CTS) than those without CTS (1, 458.3±1, 724.4 vs. 393.8±539.7ng/ml, p<0.01). Serum HA correlated positively with HCD (r_s=0.42, p<0.05) and with NCD (r_s=0.55, p<0.01). From these results, serum HA is considered to reflect synovial thickness, a known objective marker of dialysis related amyloidosis. The increased production of HA from the synovium was suggested as a possible cause.

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The site of first choice for creating an arteriovenous fistula (AVF) is still the distal forearm at the wrist or the anatomical snuff box (Tabaciere).
However, there are patients in whom this is impossible. This might be because the forearm veins are too small or have been severely damaged by frequent venopunctures or pre-existing AVF.
Patients with diabetic nephropathy, senile patients and those undergoing long term hemodialysis and so on also constitute a particularly difficult group.
Consequently, several modified procedures-the use of proximal arm veins, for example-have been designed for creating AVF in the patients who lack suitable veins at the forearm. AVF created at or near the cubital fossa amounted to about 10% of 288 new cases treated at our facility in the past 5 years; and 1.6% in 1988, 1.8% in 1989, 10.4% in 1990, 16.4% in 1991 and 19.4% in 1992. Recently the number has clearly been increasing. In this regard, AVF created at or near the cubital fossa in our 66 cases were evaluated retrospectively.
It is desirable for us to choose a method in which the median cubital vein, cephalic and basilic veins of the upper arm can be punctured but since available veins for AVF at or near the cubital fossa vary from case to case, we had to employ several different operative methods, which were roughly classified into 5 types. The artery used for the anastomosis was the radial or brachial artery. It is crucial for venous networks and deep branches of the vein used for the anastomosis to be ligated as extensively as possible in order to secure the shunted blood flow.
There were no early failures and only 14 late failures.
The high patency rate and minimal postoperative complications were considered acceptable in these otherwise difficult patients.

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We assessed the incidence and features of dementia in elderly CHD patients and the management and nursing problems encountered in caring for these patients. Nurses at the Nakano Clinic and Kidney Center of Nakano General Hospital tested 30 CHD patients aged 65 years or older by using the GBS-scale, a reliable scale for dementia with 4 subscales measuring motor, intellectual and emotional functions and different symptoms characteristic of dementia. Twenty to 30% of the elderly CHD patients showed dementia symptoms. Close relationships were observed between impairment of motor and intellectual functions, and between impairment of intellectual and emotional functions. The degree of dementia among those on CHD was more marked in inpatients than in outpatients. Also, the degree of dementia was more remarkable in patients with a CHD duration of less than 1 year than in those with a longer duration. In conclusion, 20 to 30% of elderly patients on CHD may be expected to have dementia; the important point in managing such patients is to avoid long-term admission and to educate families to assist these patients in receiving regular outpatient CHD treatment.

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Restriction of sodium and fluid intake is important in the management of hemodialysis (HD) patients. However, such patients are known to frequently be insensitive to salty taste and to often gain weight due to excessive salt and water intake. We investigated the relationship between loss of the salty taste sense and increased weight in 61 patients on maintenance HD treatment. The patients tasted a curry and rice dish served for lunch once a week for 3 consecutive weeks and were asked to rate the salty taste as weak, suitable or strong. We changed the amount of sodium chloride contained in the curry and rice dish from 1.5g to 2.0g and then 3.0g in each respective week, without the patients' knowledge. Patients also answered a questionnaire on whether they were conscious of changes in their taste sense after the intiation of HD. Fifty-two of 61 (85.2%) HD patients were insensitive to salty taste. Increasing weight between successive HD treatments was most remarkable in patients who showed a loss of salty taste and were not conscious of taste changes. Patients who were aware of taste changes after the start of HD did not gain much weight even if they were not sensitive to salty taste. We conclude that most HD patients are insensitive to salty taste; however, even these patients can overcome this loss and control their weight adequately by paying proper attention to salt and water intake.

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A 57-year-old man with cryoglobulinemia Type II associated with primary macroglobulinemia presented with dizziness and Raynaud's phenomenon. A good clinical course was achieved, and has lasted for a year, through the use of maintenance double filtration plasmapheresis (DFPP) every three weeks in conjunction with melphalan and prednisolone therapy. The values of IgG, IgA, IgM, C3, C4, and CRP in the patient's serum were abnormally high as measured by laser nephelometry. The patient's M-protein (IgM) showed abnormally high rheumatoid factor (RF) activity. Therefore, we examined these parameters more precisely by using the single radial immunodiffusion method (SRID). We conclude that IgM values should be measured by SRID when the patient's M-protein indicates abnormally high RF activity and that IgM values measured by both SRID and plasma viscosity are useful indices of DFPP.

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Two cases with chronic renal failure showing markedly elevated serum creatine kinase activity (CK, case 1: 1, 720IU, case 2: 24, 200IU) are reported. Appreciable portions of the serum CK-activity existed in association with IgA-κ, λ in both cases. In both cases, the serum CK levels decreased in response to a low protein diet. In case 2 on hemodialysis, a further decrease in serum CK was observed in parallel with a declining BUN concentration. Oral corticosteroid administration was effective in this patient. During hospitalization, rectal carcinoma was detected in case 1. Surgical removal of the carcinoma did not alter the blood CK levels.

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A 66-year-old female with chronic renal failure due to SLE had been on maintenance hemodialysis in the referring hospital for 9 months. She noticed continuous gross hematuria from May, 1989. A right renal pelvic tumor was diagnosed with CT scan. She was referred for treatment of the tumor on November 7, 1989. Because of cardiovascular disorders, only right nephrectomy was done. Pathology of the resected specimen was grade II, transitional cell carcinoma (TCC). No postoperative adjuvant therapy was done. Her postoperative course was uneventful until gross hematuria developed in November, 1990. Cystoscopy revealed many small papillary tumors at the right ureteral orifice and on the left lateral bladder wall. The patient was again admitted on November 15, 1990. Right retrograde ureterography revealed no tumor. Transurethral resection of the bladder tumor (TUR-Bt) was carried out. Pathology of the resected specimen was grade I, TCC. The patient was discharged without adjuvant therapy.
Gross hematuria was again noticed in January, 1991. The patient was admitted on January 29, 1991. Cystoscopy revealed numerous small tumors adjacent to the left ureteral orifice and on the floor of the bladder. Bilateral retrograde ureterography could not be done because neither ureteral orifice was patent due to the previous TUR-Bt. The possibility of bilateral ureteral tumors could not be ruled out. Under a preoperative diagnosis of multiple cancers of the urinary tract, the entire urinary tract (left kidney, bilateral ureters, bladder and urethra) was removed on February 12, 1991. Pathology was grade I, TCC. At present the patient is on maintenance hemodialysis at the referring hospital and free from tumor recurrence 25 months after the last operation.

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We report a long term hemodialysis patient who experienced successful pregnancy and delivery.
The patient was a 41-year-old woman with a history of hemodialysis treatment for 13 years. Her menstruation cycle was irregular because of anemia. After erythropoietin therapy, it became regular and she conceived. She was cared for as an inpatient on and after the 20th gestational week and 5 hour hemodialysis was carried out 3 times per week. Then, after the 24th gestational week, 4 hour hemodialysis was carried out 6 times per week to keep her predialysis BUN and creatinine levels under 60mg/dl and 6.0mg/dl, respectively. Hematocrit was kept above 25% by erythropoietin supplementation, and hypotension during hemodialysis treatment was prevented by slow and frequent hemodialyses. Her post-dialysis weight setting was gradually increased according to the growth of the fetus. Polyhydramnios was observed from the 20th to 25th gestational weeks, but had disappeared by the 27th week of gestation. During pregnancy, BPD, FL, HL, FTA, EFBW increased to within normal range and no abnormalites were observed on echography. At 32 weeks and two days of gestation, she delivered a baby by Caesarean section under general anesthesia. The new born baby's Apgar score was 8 points and his general condition was good except for a low body weight of 1, 462g. During the postpartum period, mother and baby had no problems, and the baby was discharged with a body weight of 3, 332g, on the 75th day after birth.
Abortion and premature delivery occur frequently in the pregnancies of hemodialysis patients. It is possible, however, for patients to deliver healthy babies if intrauterine infection and polyhydramnios are prevented as these are the causes of abortion and premature delivery.

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