Fever is one of the well known phenomena complicating chronic hemodialysis (HD) therapy. Although dialysis membranes are generally considered to be impermeable to bacterial endotoxin (ET) contaminated in dialysates used for HD therapy since ET molecular weight in aqueous media have been reported to exceed 10⁶ dalton, fever developing in patients during hemodialysis has been suggested to be associated with bacterial contamination in the dialysate. However, there are few reports concerning its molecular weight in such dialysates.
We have already reported a newly developed polyacrylamide gel electrophoresis with sodium deoxycholate (DOC-PAGE) which provides the ET molecular weight. Using this method, therefore, we attempted to determine the molecular weight of ET in dialysates. We demonstrated that ET in dialysates were of roughly two different types with DOC-PAGE and that, as compared to migration profiles of Salmonella ET as controls on DOC-PAGE, one molecular weight of ET was approximately 4, 000 while the other was tens of thousands. This investigation indicates the possibility of ET transfer across dialysis membranes.

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Six hemodialysis patients with associated urothelial cancers (one renal pelvic, ureteral and bladder cancer, five bladder cancers) treated at the Department of Urology, Tokyo Metropolitan Toshima Hospital, between January 1983 and December 1992 were investigated.
The chief complaint was gross hematuria in all six cases. The duration of hemodialysis until the cancers were found, was 1 to 96 months, and in four cases the cancers were found within two years. Three patients were treated by transurethral resection, and the others were treated by total cystectomy (one case also underwent total nephroureterectomy). Pathological diagnosis was grade 3 in all cases, and three patients had invasive cancers.
Lymphocytes were less 1, 000/mm³ in four cases, and their responses to the lymphocyte stimulating test were poor. However, all classes of immunological globulins were normal in all cases. Immuno-suppressive acidic protein was higher in all cases than in normal controls. These results indicate that immunity, especially cellular immunity, may be decreased in hemodialysis patients.
The data suggest that lower cellular immunity during hemodialysis may be responsible for the carcinogenesis of urothelial tumors and their rapid progression. Care should be taken in dealing with hematuria during hemodialysis, and examinations for urothelial cancer are mandatory.

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In order to check the effect of the leakage current generated by a computer assisted patient monitoring system and the fluctuation of leakage current from the medical equipment around the system and while the equipment itself is in operation simultaneously, we analyzed the leakage current from grounding, enclosures of the hemodialysis console and the patient leakage current.
The leakage current was also analyzed when the monitoring system and the other equipment were in operation simultaneously.
1. Regarding the patient monitor with a built-in micro-computer, 2 out of 8 had a generated leakage current exceeding the JIS standard. 2. We observed a tendency for the leakage current to increase under the following conditions. 1) when grounding of equipment was incomplete. 2) when patient monitors were operated in proximity to assisting computers.
As a countermeasure, we made a checklist on leakage current from different types of equipment and on potential differences among the pieces of equipment used in a hemodialysis center.
The result of this study indicate that a checklist of this kind is useful for monitoring and properly regulating leakage current from the equipment in a hemodialysis center.

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Some investigations, including ours, have previously reported that compared with normal subjects, both T3 and T4 levels in dialysis patients are significantly reduced, despite the patients being considered euthyroid, because serum basal TSH levels are maintained within normal range or at the upper limit of normal. Either FT3 or FT4 is reported to be exceedingly decreased. These findings often lead to confusion in evaluating the thyroid state of these patients. Recently, an abnormality of pulsatile TSH release was identified, which may provode evidence suggesting abnormal pituitary function. In addition to total T3 (TT3) and T4 (TT4), serum levels of total protein, albumin and TBG were decreased in these patients. Both FT3 and FT4 assayed by the analogue method (A), popular for measuring free thyroid hormones, were considerably reduced, whereas FT4 measured by the equilibrium dialysis method (E), a theoretically reasonable method, was within the normal range in the majority of patients (84%). (A) has some methodological problems in assessing the free hormone levels in serum, as several investigators have reported. The two methods may yield apparently discrepant values despite measuring the same hormone. TT4 correlated positively with the fall in TBG in a significant manner. TT3 correlated significantly with a reduction in serum albumin. FT3 and FT4, as assessed by (A), showed significant correlations with TBG. Mean serum selenium (Se) values in both HD and CAPD patients were much lower than in healthy controls. There was a strong positive correlation between TT3 and Se. The TT3/TT4 ratio, one of the markers of conversion from T4 to T3, also correlated with the Se level. Recently, it has been clarified that type I 5'-deiodinase is a selenoenzyme. These results are compatible with findings in Se-deficient rats. Our data suggest that FT4 in hemodialysis patients is normal and that a reduction in serum selenium appears to cause impairment of outer-ring deiodination of T4 in these patients.

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In 47 patients undergoing regular hemodialysis (HD), plasma levels of thrombomodulin (TM), thrombin-antithrombin III complex (TAT), protein C, protein S and plasmin-α₂ plasmin inhibitor complex (PIC) were measured pre- and post-HD to evaluate the blood coagulation-fibrinolysis system, and to study the antithrombogenicity of various dialyzer membranes.
Pre-HD levels of TM and TAT were both significantly increased as compared with normal control values, but those of protein C, protein and PIC were not significantly changed. Pre-HD patients were considered to be in a state of hypercoagulability.
Post-HD levels of TM and TAT were both significantly higher than pre-HD levels, such that vascular endothelial cell injuries and hypercoagulability were considered to occur during a single HD session. Post-HD levels of protein C and protein S were not significantly increased, but those of PIC were significantly higher than pre-HD levels. Therefore, fibrinolytic activity was considered to be higher in post-HD patients.
In patients dialyzed with EVAL and polysulfone membranes, post-HD levels of TM, TAT, protein C, protein S and PIC were not significantly different from pre-HD levels, such that these membranes were considered to have good biocompatibility. In contrast, in patients dialyzed with regenerated cellulose and PMMA membranes, post-HD levels of TM, TAT and PIC were significantly higher than pre-HD levels. A single HD session using these membranes might have evoked the vascular endothelial cell injuries, hypercoagulability, and enhancement of fibrinolytic activity observed in HD patients.

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Subclavian vein thrombosis and/or stenosis has been reported as a frequent complication of vascular access in hemodialysis patients who have undergone venous catheterization for temporary blood access. It rarely occurs, however, in patients without predisposing catheter cannulation.
We observed cases of proximal subclavian vein stenosis and brachiocephalic vein stenosis on the same side as an existing arteriovenous (A-V) fistula in patients who had no venous catheterization.
The first case was a 19-year-old male who had a right A-V fistula between the brachial artery and the medial cephalic vein. Right upper arm and neck edema developed 7 years after establishment of the fistula. Venograms and magnetic resonance angiography (MRA) showed remarkable stenosis of the right subclavian vein at the site of the thoracic outlet. He was treated with percutaneous transluminal angioplasty (PTA), but the stenosis recurred 4 months later. After a second PTA therapy, combined with surgery to reduce the blood flow of the A-V fistula, his symptoms disappeared.
The second case was a 48-year-old male who had a left A-V fistula between the brachial artery and the medial cephalic vein. He experienced left upper arm and shoulder edema and pain during hemodialysis treatment. Venography and MRA revealed remarkable stenosis of the left brachiocephalic vein just distal to the inflowing axillary vein. He was treated with PTA, and surgery was performed to reduce the blood flow at the A-V fistula, but the A-V fistula occlusion relapsed 3 months later. His symptoms disappeared after reconstruction of the obstructive lesion was achieved. Histopathological findings of the resected vein revealed severe endothelial thickening and narrowing around the valve.
The following conclusions are documented and discussed. 1) There is the possibility that venous stenosis and/or thrombosis can occur in hemodialysis patients without predisposing catheter cannulation. 2) There are two major reasons for venous stenosis: the first is blood overflow from an A-V fistula, the second is anatomical narrowing at the thoracic outlet (1st case) and around the venous valve (2nd case). 3) PTA and/or reconstruction against a stenotic vein should be done in combination with an operation to reduce A-V blood flow.

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It is well-known that acute pancreatitis is a major complication in patients undergoing hemodialysis or renal transplantation. It is also recognized as one of the complications occurring in patients undergoing CAPD. We report here three CAPD cases with acute pancreatitis.
Case 1; a 43-year-old male who started CAPD in October, 1987, developed epigastric and back pain in May 1990. His blood tests revealed elevations of WBC counts and the serum amylase level. His symptoms and blood testfindings improved after removal of the peritoneal catheter.
Case 2; a 52-year-old female who started CAPD in November, 1987, was admitted to our hospital due to peritonitis in December of 1992. Her blood tests also showed marked elevations of serum amylase and elastase I. Computerized tomography revealed that she had a pancreatic cyst due to acute pancreatitis and a right renal tumor. After removal of the renal tumor, her general condition and serum levels of amylase and elastase I returned to normal.
Case 3; a 48-year-old female who started hemodialysis in 1972 and switched to CAPD in May, 1989, developed acute pancreatitis after a right femoral fracture. Two months after admission, she developed acute hemoperitonium and died. Her autopsy findings showed rupture of a pseudoaneurysm in the pancreatic artery due to the invasion of a pancreatic cyst.
We experienced three cases (2.1%) of acute pancreatitis in a total 140 patients undergoing CAPD in our hospital. This figure was significantly higher than those for hemodialysis or transplantation. It is suggested that CAPD procedures may play an important role in the development of acute pancreatitis.

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We report two cases maintained on continuous ambulatory peritoneal dialysis (CAPD) who developed destructive spondyloarthropathy (DSA). One patient was a 59-year-old male who had been on CAPD for 10 years, the other a 43-year-old female on CAPD for 5 years who had been maintained on hemodialysis for the previous 10 years. Their DSA were progressive despite adequate CAPD treatment. Thus, CAPD treatment is not sufficient for the removal of β₂-microglobulin. Dialysis associated amyloidosis, such as DSA, should be avoided in CAPD patients as well as long-term hemodialysis patients.

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A 54-year-old female patient with Wegener's granulomatosis who had received maintenance hemodialysis for 8 years is reported. Hemodialysis was started due to rapidly progressive glomerulonephritis and glucocorticoid treatment was initiated because of polyarthralia and a high titer of rheumatoid factor. She suffered from nasal sinusitis 6 years later, and was admitted to our hospital 8 years later because of severe skin rash affecting the extremities with blisters and ulcers. She had never experienced pulmonary complications. Biopsy findings of the kidney, sinus mucosa and skin were compatible with Wegener's granulomatosis. C-ANCA was 88U on admission and decreased to 24U after remission was achieved with corticosteroids. C-ANCA is a useful tool for diagosing and evaluating the therapy for Wegener's granulomatosis.

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A sixty-four-year-old male had been treated with CAPD using Dianeal^® since September of 1986. The dialysate was changed to Dianeal PD-2^® in December of 1988, because of gradual elevation of his serum magnesium concentration. A minute calcification on the non-coronary cusp of the aortic valve was first revealed by echocardiography in June of 1988. The valvular calcification progressed over the next 3 years, and severe aortic stenosis ensued. He developed sudden cardiac death in October of 1991. The gross appearance of the autopsy materials indicated that the valvular calcification was compatible with a diagnosis of aortic calcific stenosis.
In the present case, there was no evidence of the causes of metastatic calcification commonly observed in dialysis patients. On the other hand, his plasma level of bicarbonate was elevated to a range of 23-27mEq/l after the application of Dianeal PD-2^®. Since metabolic alkalosis has been known to accelerate calcium deposition in soft tissues, it was suggested that an elevated plasma bicarbonate concentration might have caused the rapid progression of valvular calcification.

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We report a peritoneal dialysis patient who underwent laperoscopic cholecystectomy and was able to resume peritoneal dialysis. A 62-year-old female with a diagnosis of gallstones was admitted for laparoscopic cholecystectomy. The patient was on bagless CAPD with a set drainage system (JMS, 2L).
The patient underwent laparoscopic cholecystectomy. Hemodialysis was started on the second postoperative day. On the thirteenth day after surgery, CAPD was restarted with 1L exchange of 1.55% dextrose dialysate. On the fifteenth day after surgery, CAPD was continued with four 2L exchanges of 1.55% dextrose dialysate with similar dwell times-the normal CAPD routine for this patient. No complications occurred after surgery. Laparoscopic cholecystectomy is a valuable alternative to open cholecystectomy, especially in CAPD patients. This procedure should be considered for any CAPD patient requiring cholecystectomy.

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Pemphigus vulgaris is a disease presenting with various-sized blisters. It is known that the titer of anti-intercellular antibody correlates closely with clinical findings. We experienced a case of pemphigus vulgaris who had multiple organ failure in whom treatment with double filtration plasmapheresis (DFPP) was effective.
A 57-year-old woman was admitted because of generalized blisters and erosions. On admission, she had oliguria, azotemia, liver dysfunction, and skin infection due to staphylococcus sp. and pseudomonas sp. The antibody titer was very high, being 10⁴.
We initiated respiratory support with a respirator, frequent hemodialysis and blood transfusion. Administration of antibiotics and high doses of corticosteroids was done simultaneously. Despite this aggressive treatment, the skin lesions did not improve and sepsis developed. We had to reduce the corticosteroid dosage and performed 6 courses of DFPP to reduce antibody levels. With treatment, the antibody titers gradually decreased and improvement of her general condition was observed.
This case shows that DFPP, in combination with corticosteroids, reduces circulating antibody levels more rapidly than conventional therapy and is effective treatment for pemphigus vulgaris without the use of high dose corticosteroids.

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