Coronary artery disease (CAD) contributes to high mortality rate in end-stage renal disease (ESRD) patients. Single photon emission computed tomography (SPECT) using ²⁰¹Thallium (TI) or ^99mTechnetium-labeled tracers has been used to detect CAD, but they require physical or pharmacological stress loading. Resting SPECT using an iodinated fatty acid analogue, 15-(p-[I-123]-iodophenyl)-3-(R, S) methylpentadecanoic acid (¹²³I-BMIPP), can assess fatty acid metabolism in the myocardium. We investigated the ability of ¹²³I-BMIPP SPECT to detect CAD in hemodialysis patients, and compared with ²⁰¹TI SPECT. We prospectively enrolled 130 ESRD patients undergoing hemodialysis with a mean duration of 88.6 months (male/female: 77/53, mean age: 63.8 years). Dual SPECT using ¹²³I-BMIPP and ²⁰¹TI was performed, which was followed by coronary angiography (CAG). SPECT imaging was evaluated and graded in 17 segments using a five-point scale (0=normal, 4=absence). Final assessment was based on the summed score. On CAG, 71.5% of patients (93/130) showed a significant coronary stenosis (≥75%), and 5 patients showed coronary spasm without coronary stenosis. When a BMIPP summed score of 6 or more was defined as abnormal. Its sensitivity, specificity, and accuracy for detecting CAD by BMIPP SPECT were 98.0, 65.6, and 90.0%, respectively. In contrast, these parameters for detecting CAD by TI SPECT were 84.7, 46.9, and 75.0%, respectively, when a TI summed score of 1 or more was defined as abnormal. In receiver operating characteristic (ROC) analysis, the area under the curve indicating the ability to diagnose CAD was 0.895 in BMIPP and 0.727 in TI SPECT. Resting BMIPP SPECT imaging is superior to TI SPECT for detecting coronary lesions, and provides safe screening for CAD among maintenance hemodialysis patients.

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Percutaneous maxacalcitol (OCT) injection therapy (PMIT) has been developed as an effective and safe treatment for advanced secondary hyperparathyroidism (SHPT). The effect of PMIT on PTH suppression was evaluated by intact PTH, highly sensitive (HS) PTH, and whole PTH assays.
Eight dialysis patients with SHPT resistant to intravenous OCT administrations were consecutively treated by PMIT six times a week followed by OCT intravenous administrations (iv OCT). Serum intact PTH, HS PTH, whole PTH, Ca adjusted for albumin, and P levels were measured before, immediately, 4 and 12 weeks after PMIT.
After PMIT, serum intact PTH, HS PTH, and whole PTH levels were significantly decreased, however serum adjusted Ca and P levels did not change significantly. Whole PTH/C PTH (calculated by intact-PTH-whole PTH) ratio was also significantly decreased immediately after PMIT. In five patients whose PTH levels were controlled by iv OCT for more than 6 months after PMIT (effective group), the decrease in whole PTH level after PMIT was significantly greater compared with that in the ineffective group whose PTH levels could not be controlled by iv OCT.
It is suggested that whole PTH difference immediately after PMIT compared to that before may predict the effect of PMIT.

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An 83-year-old woman on hemodialysis was hospitalized due to high fever and vomiting. On admission, she was diagnosed as having Influenza A virus infection based on examination by influenza virus antigen kit. Despite treatment with amantadine and β-lactum antibiotics, pulmonary infiltration and hypoxemia developed. Therefore, we carefully examined her serum and she was subsequently as having diagnosed Legionella infection based on positive findings using a serum Legionella antigen kit. She rapidly recovered from Legionella pneumonia after administration of erythromycin, rifampicin and levofloxacin. Serum Legionella antigen is of enourmous value in identifying Legionella infection in a hemodialysis patient.

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We report a case of acute superior mesenteric artery occlusion with hepatic portal venous gas in maintenance hemodialysis patient. The patient was a 58-year-old male undergoing hemodialysis treatment for chronic renal failure due to diabetic nephropathy since 1994. He was admitted to our emergency room because of abdominal pain developed at night on January 9, 2001. On the following day, a celiotomy was carried out because computed tomography scans demonstrated the presence of hepatic portal venous gas. Wide spread bowel necrosis was identified from the region 80cm on the anal side, from Treiz ligament to 5cm on the oral side from the ileum end. Necrosis was diagnosed to be due to superior mesenteric artery occlusion. Intestines was excised by about 320cm in length. Diarrhea caused by short intestine syndrome persisted, and TPN was started on February 20, 2002. A ingestion of enteral nutrition became possible, and he was discharged from hospital on April 23, 2002.

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A 68-year-old female with autosomal dominant polycystic kidney disease (ADPKD) on hemodialysis underwent transcatheter arterial embolization (TAE) of the renal arteries with complaints of dyspnea and gastrointestinal symptoms due to enlarged kidneys. One month after renal TAE, consciousness disturbance associated with hyperammonemia occurred. Abdominal angiography demonstrated a spleno-renal shunt and was suspected to the cause of portal-systemic encephalopathy. Since hyperammonemia was resistant to lactulose and branched chain amino acid, the shunt-preserving disconnection of portal and systemic circulation using an interventional radiology method was selected. After successfully performing this procedure, consciousness disturbance improved. It is suggerted that the blood flow of the hepatic and portal vein were obstructed by the massive hepatic cysts, and it goes into the extra portal vein including the splenic vein, resulting in a spleno-renal shunt. The preexisting spleno-renal shunt became symptomatic due to changes in hemodynamics after renal TAE. The renal TAE therapy in ADPKD patients was started in 1996 and has been reported to be a safe and effective therapy. However, there is a possibility of both portal-systemic shunt and portal hypertension in patients with ADPKD. This is the first case of ADPKD patient who developed portal-systemic shunt encephalopathy after this procedure.

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We experienced a patient who had specific autoantibodies, which made blood transfusion difficult during percutaneous coronary intervention (PCI) for angina pectoris. A 69-year-old male had been undergoing maintenance hemodialysis for chronic renal failure due to chronic nephritis. As anginal attack frequently developed during hemodialysis, cardiac catheterization and PCI were scheduled for further examination. Preoperative examination showed severe anemia. Therefore, a cross match test was performed, considering the necessity of blood transfusion during PCI. However, aggregation was observed in all of the same type stored blood products. Thus, adequate blood products could not be obtained. The further examinations revealed anti-C+anti-e+autoantibodies without blood type specificity in the patient's serum. Some patients undergoing chronic hemodialysis have a history of blood transfusion for renal anemia, and the incidence of ischemic heart desease is high. Blood transfusion is sometimes required during PCI. We consider that autoantibodies are an important problem in the treatment of ischemic heart disease in patients undergoing maintenance hemodialysis.

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A 20-year-old man was admitted to our hospital because of abdominal expansion and vomiting. Abdominal X-ray and computed tomography (CT) scan disclosed massive air with fluid retention in the stomach. After extraction of gastric air and contents by a gastric tube, shock occurred with progression of anemia and multiple organ failure including acute renal failure. Gastroduodenoscopy demonstrated widespread gastric mucosal necrosis without gastroduodenal stenosis, a finding of mucosal necrosis induced by acute gastric dilatation. Because of his poor condition, total gastrectomy was not performed. Continuous hemodiafiltration (CHDF) was started, and blood transfusion and administration of total parenteral nutrition as well as H₂ blocker were done. He recovered from shock and showed improvements of multiple organ failure, gastric dilatation and mucosal necrosis. Although most reported cases of acute gastric dilatation with continuing hemorrhage require surgical treatment, the present case was successfully treated with conservative treatment. Especially, CHDF was effective probably by removing toxic factors including cytokines.

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We encountered two cases of chronic renal failure expressing pronounced leukocytosis and shock due to pseudomembranous colitis (PMC) requiring endotoxin adsorption using polymyxin-B immobilized fiber (PMX).
Case 1: female, age 81. She received regular outpatient treatments of chronic renal failure. Hemodialysis was introduced when she developed acute bronchitis. We administered cefotiam for seven days, and then, cefazolin for five days to control infection. On this occasion, diarrhea, fever and abdominal discomfort developed. We thought that these symptoms were caused by bacterial enteritis and continued to administer antibiotics. However, the symptoms were not eliminated. Thereafter, she developed pronounced leukocytosis (31, 200/μL) and shock. Although blood pressure was temporarily elevated by PMX, the patient died the following day.
Case 2: female, age 67. She received regular outpatient treatments for diabetes and chronic renal failure. She was administered levofloxacin against fever; however, the symptom was not eliminated. Pronounced leukocytosis (54, 800/μL) and diarrhea were observed and we suspected PMC. We administered a preparation of lactobacillus and followed the course. Since she developed shock, we performed PMX and the hemodynamic state was improved. At a later date, we administered meropenem against catheter fever for four days and she again developed PMC and shock. The second PMX was highly effective. The symptoms did not recur after administering vancomycin.
Pronounced leukocytosis appeared to be a useful sign for diagnosing PMC. It was supposed that PMX was effective for septic shock accompanying PMC and should be performed without delay if the patient is refractory to conservative medical management.

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