Although clinical benefits associated with low sodium dialysate in CAPD such as higher removal of sodium and water have been reported elsewhere, its mechanism is still speculative.
To assess mass transport characteristics by this unique dialysate composition we utilized mathematical model being reported previously. In this computer simulation 8.3ml/min, 9.4ml/min and 10ml/min of mass transfer area coefficients (MTAC) for sodium, chloride and glucose were cited from the literatures. Sodium concentrations in dialysate were varied from 76mEq/l to 129mEq/l, compensating its associated decreases of osmolarity by glucose.
An increase of approximately 22ml of net ultrafiltration volume at 6hr dwell time could be achieved by reduction of 1mEq/l of serum sodium concentration in the range of 130mEq/l-150mEq/l of serum sodium concentration while only 2.3-0.5ml of net UF volume increase per 1mEq/l of dialysate sodium concentration decrease could be estimated in the range of 76mEq/l-129mEq/l of dialysate sodium concentration. 20% and 41% of sodium were transported by diffusion in standard dialysate (129mEq/l) and LNaD (102mEq/l), respectively.
It is clearly indicated that diffusive transport becomes dominant in sodium removal as sodium concentration in dialysate decreases, while both increase of reflection coefficient and decrease of MTAC of sodium tend to reduce water removal.

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Recently, plasma levels of ANP and its second messenger cGMP have been shown to be potential indices of fluid retention in patients on maintenance HD. We previously reported that the ultrasonographically determined diameter of the inferior vena cava during expiration (IVCe) changed in parallel with the circulating blood volume (CBV) during HD therapy. In addition, IVCe was found to be a good index of plasma refilling after one session of HD therapy. Therefore, the present study was undertaken to evaluate the usefulness of plasma ANP and cGMP concentrations for estimating plasma refilling rate in patients on maintenance HD.
Ten patients (6 males, 4 females, age; 34-77 years) on maintenance HD were involved in the study. Blood samples for ANP, cGMP, hematocrit (Ht), total protein (TP) and albumin (Alb) were collected before and 0, 0.5, 1, 2 and 6 hours after one session of HD therapy. Measurements of IVCe were also performed at the same time that blood samples were taken.
Following the removal of an average of 2.0kg of water, ANP, cGMP and IVCe decreased by an average of 44, 47 and 29%, respectively. However, the values of Ht, TP and Alb increased significantly after HD. While plasma ANP levels slowly recovered after hemodialysis, its levels remained significantly lower than those at predialysis at 6 hours after HD. The values of IVCe quickly recovered at 1 hour after HD. Changes in cGMP levels were similar to those of IVCe levels during this study. There was a significant correlation between the percentage changes in plasma ANP and Ht, and between cGMP and IVCe values.
Plasma ANP and cGMP levels may be useful in the estimation of plasma refilling rates, along with the measurements of IVCe in patients on maintenance hemodialysis.

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From 1982 to December 1993, parathyroidectomies were performed in 30 patients with secondary hyperparathyroidism who were undergoing hemodialysis. They consisted of 12 males and 18 females, whose ages ranged from 26 to 66 years.
Thyroid tumors were found in 10 (33.3%) patients: 7 with papillary carcinomas (23.3%), and 4 with follicular adenomas (13.3%). One patient had both papillary carcinoma and follicular adenoma. In 2 cases, carcinomas were in the occult state and 3 cases showed metastasis at resected lymph nodes. There were no age or sex differences between the patients with thyroid tumors and those without tumors, but patients with thyroid carcinoma were significantly older than patients without thyroid carcinoma. The level of thyroxine in patients with thyroid carcinoma (6.8±1.7μg/ml) was higher than in patients without thyroid tumors (4.9±2.2; p<0.05). The levels of serum calcitonin in patients with thyroid carcinoma (150.3±37.7pg/ml) was higher than that in the patients with adenoma (115.7±32.7pg/ml; p<0.05). The levels of serum PTH, calcium and alkaline phosphatase were similar in these three patient groups.
In conclusion, the incidence of thyroid carcinoma was high in dialysis patients with secondary hyperparathyroidism and thyroid carcinoma was often an incidental finding at operation for secondary hyperparathyroidism. Consequently, careful diagnosis and histological examination should be performed in all patients.

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Questionnaires were sent to 2, 421 dialysis units in February 1994, to determine the present status of renal cell carcinoma in chronic hemodialysis patients. The response rate was 59.9%. Renal cell carcinomas were detected in 273 dialysis patients between March 1992 and February 1994. The age of the 273 patients (216 males and 57 females) was 53.5±11.3 (mean±SD) years, and the mean duration of dialysis was 118.2±71.0 months. The clinical diagnosis was based on sonographic examination (128 case) and CT scan (106 cases). Only 26 of those patients were symptomatic. Acquired renal cystic disease was found in 224 of 271 renal cell carcinoma patients (82.7%). The 210 cases with renal cell carcinoma were histologically confirmed. Cell typing of 194 renal cell carcinomas revealed that 105 patients showed the clear cell subtype, 42 the granular cell subtype and 47 a mixed cell subtype. The relationship between cell types in renal cell carcinoma and the duration of hemodialysis was studied. Granular and mixed cell subtypes were prevalent among patients who had had more than 5 years of hemodialysis. 35 out of 269 patients had metastasis. In conclusion, 273 renal cell carcinomas were found in the two years preceding this report and the prevalence was the highest to be documented in the six most recent questionnaires. The incidence of renal cell carcinoma in dialysis patients was 15 to 18 times higher than that in the general population. The incidence of renal cell carcinoma in dialysis patients showed 187 renal cell carcinomas per 100, 000 dialysis patients per year.

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The case of a 70-year-old hemodialysis patient with splenic infarction is reported.
The patient had an 11-year history of diabetes mellitus secondary to chronic pancreatitis and had been undergoing hemodialysis for the preceding 4 years. He was admitted to our hospital with persistent left upper abdominal pain. Splenic infarction was diagnosed by abdominal CT, which showed a wedge shaped, low density area in the spleen, and prominent calcification of the splenic artery. The pain persisted for about one week and then spontaneously subsided. The cause of splenic infarction was considered to be cholesterol plaque emboli from atheromatous lesions. In hemodialysis patients with severe atherosclerosis who complain of left upper abdominal pain, splenic infarction, though relatively rare, should be included in the differential diagnosis.

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This report details a case in which renal failure occurred after heart catheterization, in which the patient was diagnosed as having cholesterol atheroembolism by renal and skin biopsies. The patient was a 57-year-old man, who fell into a state of non-oliguric renal dysfunction after coronary arteriography (CAG) and percutaneous transluminal coronary angioplasty (PTCA) due to unstable angina pectoris. Thereafter the patient underwent hemodialysis. Cholesterol crystals were observed in the vascular lumen both by renal biopsy at the commencement of hemodialysis and by skin biopsy at the acrocyanotic lesions that appeared after catheterization. Catheter manipulation and subsequent excessive anticoagulant therapy were considered to be causes of cholesterol atheroembolism. In this case, renal function gradually improved while maintenance dialysis was continued and the patient was able to stop dialysis after 14 months. Cholesterol atheroembolism is therefore a potential cause of acute or chronic renal failure.

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A 30-year-old woman initially exhibited chance proteinuria at age 18. She was treated with prednisolone at age 21 for this newly developed nephrotic syndrome. The administration of prednisolone was discontinued at age 29, because renal function gradually declined and her urinary protein excretion persisted. The patient was found to be pregnant in April 1993 with a 12-week gestation. She was admitted to our hospital at 16 weeks of gestation because of progressive edema and hypertension. A serum creatinine (S-Cr) of 3.1mg/dl was detected on admission. Hypertension and edema improved after a restriction of sodium intake and rest, while her hematocrit decreased to 20.8% at 17 weeks of gestation.
Subcutaneous injection of 3, 000U rHuEPO once a week was started. As her hematocrit remained at 18.4% at 20 weeks of gestation, the dose of rHuEPO was increased to 12, 000U per week with a 400ml transfusion of red blood cells. After 23 weeks of gestation, her hematocrit was sustained at 30% or more with a weekly administration of 6, 000U rHuEPO. After 28 weeks of gestation, she was treated for hypertension, growth retardation of the fetus and a serum urea nitrogen of 43mg/dl and a S-Cr of 5.9mg/dl using HD. At 30 weeks of gestation, she delivered a female baby weighing 1, 018g by Caesarean section. Her HD treatment was discontinued one week after delivery.
This may be the first case of successful birth in Japan after treatment with rHuEPO and transient HD in a patient with CRF.

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This report details a case of interstitial pneumonia (bronchiolitis obliterans organizing pneumonia, BOOP). A 36-year-old male on hemodialysis was admitted complaining of dyspnea on exertion. Chest X-ray film showed infiltrative shadows in the right upper-middle and left upper lung fields. CT of the chest revealed an increase in density with air bronchograms. Bronchoalveolar lavage fluid findings revealed an increase in the total cell count, an increase in the percentage of lymphocytes and a decrease in the OKT4⁺/OKT8⁺ ratio. These findings suggested a diagnosis of BOOP. After treatment with corticosteroids, but not antibiotics, the abnormal opacities disappeared. If infiltrative shadows on the X-ray film do not improve with antibiotics in hemodialysis patients, should be considered as a potential cause.

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The ability of acarbose (Glucobay^®) to replace low-dose (4-8IU/day) insulin therapy was assessed in 4 patients (mean age: 56.5±2.1 year-old; mean diabetes estimated duration: 17.5±7.3 years; mean duration of dialysis: 21.5±6.5 months; mean insulin dose prior to acarbose: 6.5±1.9IU/day) who exhibited diabetic nephropathy and were maintained on dialysis. Good control of HbA_1c (7-8%) was achieved but patients presented with hypoglycemia during dialysis. On the day following insulin withdrawal, acarbose therapy at a daily dose of 300mg (150mg for patient 3 only) was initiated. HbA_1c and fructosamine (FRA) levels, as well as abdominal symptoms starting at 12 to 15 months after replacement were compared to those observed at 9 months prior to replacement. Patient 1 was a 54-year-old woman. Following replacement of insulin, her HbA_1c and FRA values were significantly reduced along with a transient improvement in bowel movement. Patient 2 was a 59-year-old man. Fifty days after the replacement of insulin anorexia developed, and insulin therapy was resumed. Subsequently he regained his appetite, but HbA_1c and FRA values increased, requiring a higher insulin dose (monotard insulin: 8IU/day→12IU/day). Patient 3 was a 57-year-old woman. Her HbA_1c and FRA were maintained at similar levels, but a pre-existing alternate stool abnormality was exacerbated. Patient 4 was a 59-year-old man. His HbA_1c and FRA were maintained at similar levels, but transient tarry stool required acarbose therapy suspension. Acarbose, which replaced insulin, continued to achieve good control of blood glucose as evidenced by HbA_1c and FRA values that remained steady or lowered. However, acarbose did cause abdominal symptoms severe enough to require drug suspension or discontinuation in some patients.

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This report details the first Japanese case of spontaneous gallbladder bleeding occuring in a maintenance hemodialysis patient, treated by urgent cholecystectomy. Maintenance hemodialysis was started in this 53-year-old man with gouty nephropathy in July, 1992. On July 13, 1995, he was admitted to San-ai Memorial Clinic because of an acute upper abdominal pain. Laboratory tests showed high GOT/GPT (132/60IU/l) levels. Abdominal ultrasonography revealed an enlarged gallbladder filled with hyperechoic material. On July 15, serum bilirubin and K levels increased to 6.6mg/dl and 7.5mEq/l, respectively. After hemodialysis, the patient was examined through a midline incision. A large tense gallbladder was found and was excised. Intraoperative sectioning revealed a thickened inflammatory gallbladder wall and a large blood clot that filled the lumen indicating hemorrhagic cholecystitis.
Intraoperative cholangioscopy revealed viscous hemobilia obstructing the common bile duct as the cause of janudice. A T-tube drain was placed in the bile duct. The patient recovered slowly, and was discharged after one month. There has been only one report on a hemodialysis patient in Japan who died due to gallbladder bleeding. Prognosis of this disease is good if an appropriate urgent treatment is carried out, and one should consider this disease in differential diagnosis of an acute abdomen in patients on hemodialysis.

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In order to clarify the definition, diagnosis and treatment of scelerosing encapsulating peritonitis (SEP) in patients with CAPD, a consensus meeting on SEP was held in Tokyo, on October 13 and 14, 1995. We defined SEP as a clinical entity which develops clinical symptoms due to bowel obstruction in patients receiving peritoneal dialysis. Its clinical features are nausea, vomiting and abdominal pain in all patients. In addition, we see malnutrition, weight loss, diarrhea, constipation, slight fever, bloody dialysate, localized or diffuse ascites and decreased bowel movement in some patients with SEP. An abdominal mass consisting of adhesive small bowel is palpable in such patients. Histologically, we observe peritoneal thickening and/or sclerosing peritonitis in peritoneal tissue specimens from patients with SEP. The use of radiological and ultrasonic evaluation is very helpful for diagnosis in patients with SEP. The basic strategy for the treatment of SEP is to sustain the rest of the bowel. Intravenous hyperalimentation (IVH) therapy is effective in the treatment of patients with SEP. It was concluded that constant clinical, radiological and/or ultrasonic surveillance is necessary to detect SEP in patients during CAPD.

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