The long-term efficacy of endotoxin (ET) removal of two type hollow fibers with a polysulfone (PS) membrane (CF-609, Nipro, Osaka, Japan, cut-off 6000, surface area 0.9m² and TET-1.0, Toray, Tokyo, Japan cut-off 70000, surface area 1.0m²) was evaluated for 16 months. All output samples through CF-609 showed that the ET levels were below the sensitivity (1.34EU/l) of a limus amoebocyte lysate assay up to 1656 hours. The ET activity of the filtrate ranged from 1.5 to 3.9EU/l in TET-1.0 over 670 hours. There were no membrane failures, and dialyste flow was maintatined at 500ml/min during the test period. Electron microscopic examination revealed that TET-1.0 has micropors on the surface of fibers but CF-609 does not. In conclusion removal of ET can be achieved by prolonged ultrafiltration through a PS membranes. The ultrastructual difference of the two membranes may influence the efficy of ET removal after prolonged use.

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A fifty-five year old man who had been maintained on hemodialysis for and half years due to chronic renal failure demonstrated bilateral small cell renal carcinomas on annual CT examination. He had no local or distant metastasis and underwent bilateral nephrectomy by a hand assisted laparoscopic procedure. Both kidneys were safely removed through a 7.5cm-long midline incision with 5 laparoscopic ports. Surgical duration was 345 min. The resected bilateral kidneys were investigated pathologically along with sufficient Gerota's fat attached and renal cell carcinoma was detected, G1>2, pT1a, pNx. Postoperative recovery was uneventful. The hand assisted procedure facilitates not only good postoperative recovery but also satisfactory pathological findings with a freely-selected access wound, compared to both an open procedure and solely laparoscopic procedure.

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Erectile dysfunction is common in hemodialysis patients. We report our experience with sildenafil citrate in patients undergoing hemodialysis with review of the literature relating to sildenafil treatment.
Eight maintenance hemodialysis patients aged 37 to 63 (5 Diabetes Mellitis (DM), 3 non-DM patients) with a hemodialysis history of 2.9±3.1 years were evaluated by IIEF5 (5-item version of the International Index of Erectile Function), and two patients (1 DM, 1 non-DM) were prescribed sildenafil citrate at doses of 25 to 50mg. The mean score of IIEF5 for all cases was 6.1±4.7, that of DM cases was 6.4±4.8 and non-DM 5.7±5.5. The IIEF5 scores improved from 11 to 22 points after 50mg sildenafil treatment in one DM patient. The other non-DM case had side effects of flushing and ventricular arrhythmia (Lown classification II) immediately after administration and discontinued treatment.
A review of the literature on sildenafil citrate for erectile dysfunction in hemodialysis patients including this report revealed one original paper and 12 abstracts of scientific meetings (106 cases). Sildenafil citrate were effective for 71 of 96 cases in which efficacy was described. Adverse effects were reported in 6 cases with flushing only, headache or flushing and ventricular arrhythmia. We found a significant beneficial effect of sildenafil citrate on erectile dysfunction in Japanese men on maintenance hemodialysis. To confirm these preliminary observation and reports, a randomized placebo-controlled, prospective study is needed in this unique population in Japan.

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A 69-year-old woman consulted our hospital in April 1991. She had chronic hepatitis, cardiomegaly and chronic renal failure. In December 1992, a small subcutaneous nodule appeared on her right upper arm. In June 1993, hemodialysis therapy was started. The painful skin ulcer on her right arm developed over subcutaneous calcified plaques (tumoral calcinosis), and similar lesion later appeared on the left upper arm. In September 1994, she experienced severe sinus dysfunction and an artificial pacemaker was implanted. She was admitted to our hospital in September 1997 because of lumbago and anorexia. Both upper arms were deformed by tumoral calcinosis shown by roentgenogram and a pigmented skin ulcer was present on the right arm. The analysis of calcified tissue revealed 51% of calcium phosphate and 49% calcium carbonate. The skin biopsy specimen showed many inflammatory cell infiltrations around small vessels, marked increase of fibrous tissue and scattered calcification without fatty tissue inflammation. Laboratory data showed increased i-PTH and Ca×P product. Increased subcutaneous calcification was likely to have occurred simultaneously with increasing i-PTH and Ca×P levels. She was diagnosed with hepatoma in November 1999 and she died in May 2000. Autopsy was done and calcified amorphous tumor was found adjacent to the mitral valve. On analysis, the calcified amorphous tumor was 67% calcium phosphate and 33% calcium carbonate. We reported here rare case f a hemodialysis patient with tumoral calcinosis of the proximal extremities along with cardiac calcified amorphous tumor.

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We report a case of successful surgical therapy for sclerosing encapsulating peritonitis (SEP) developed after a cadaveric donor renal transplantation. The patient was a 42-year-old male, who previously developed chronic renal failure and began continuous ambulatory peritoneal dialysis (CAPD) at the age of 34 in June 1992. Since then, the patient experienced two episodes of peritonitis. A successful cadaveric donor renal transplant was performed in January 1999, but the patient complamed of a full sensation in the abdomen and vomiting from July 1999. SEP was diagnosed on April 2000, and he was initially managed with total parenteral nutrition. The patient was admitted to our hospital and surgery was performed on 8 June, 2000. Introperatively, intraeritonial fluid, similar to bile juice was noted and two sections of the small bowel were encased in dense white fibrous tissue. The sigmoid colon was hidden behind a thick sclerotic membrane that involved the retroperitoneum. Total dissection of the encapsulated small bowel and sigmoid colon, and resection of fibrous tissue were successfully performed. Histological examination of the peritoneum revealed chronic peritonitis and peritoneal fibrosis. In the postoperative management, intravenous administration of predonine and cyclosporin A was performed for immunosuppression therapy. The patient's postoperative course was good and he was discharged on an oral diet on the 27^th postoperative day. The number of renal transplant recipients has been increasing, and in such patients treated with CAPD in whom SEP develops, surgery based on careful prioperative management should be considered as a therapeutic option.

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The patient was a 64-year-old man who had undergone hemodialysis therapy for 3 years and who presented with hoarseness in February 1998. Chest X-ray examination revealed a protrusion of the left 1st arch, which increased over a period of 6 months. He was diagnosed with a thoracic aortic aneurysm and received a bypass graft in April 1988. Seven days postoperatively the surgical wound became purulent but this was successfully treated with antibiotics. In November 1988, the patient developed low back pain and was admitted to our department on an emergency basis due to fever, chest incongruity and dysbasia with severe lumbago. On admission, leukocytosis (WBC; 13, 100/mm³) and positive C-reactive protein (20.3mg/dl) were noted and Staphylococcus aureus was detected in blood cultures. Magnetic resonance imaging (MRI) of the lumbar portion revealed pathological findings compatible with discitis at L 2/3 and spondylitis. Chest MRI at the same time, showed a low contrast tumor located around the replacement site of the aortic arch aneurysm, and mediastinitis associated with graft infection was considered. Surgery was avoided in view of the risk-benefit ratio, but continuous antibiotics were administered after determining the drug sensitivity of the bacteria. The symptoms gradually improved over a 4 month period in accordance with improved blood and radiological findings. The source of infection could not be identified. This case report highlights the susceptibility of patients on hemodialysis to bacterial infection.

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