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Adynamic bone disease (ABD) has attracted attention as the most frequent type of renal osteodystrophy, but there are few reports about the bone mineral density (BMD) in ABD patients. This study investigated the BMD in hemodialysis patients with ABD and with relatively normal bone turnover. We measured the BMD of the distal one-third of the radius by dual-energy X-ray adsorptiometry.In the ABD group (intact PTH<65pg/ml, intact osteocalcin<30ng/ml), there were 19 men and 17 women with a mean age of 56.4±12.0 years. In the relatively normal bone turnover group (intact PTH: 120-250pg/ml), there were 24 men and 16 women with a mean age of 57.1±14.7 years. Although there were no significant differences between the two groups with respect to age, gender, and duration of hemodialysis, a significant increase of the BMD and the calcium x phosphate product was observed in the ABD group (radial BMD: 0.648±0.137 g/cm2versus 0.572±0.132 g/cm2, calcium x phosphate product: 57.53±14.92 mg2/dl2versus 49.76±12.13 mg2/dl2).These findings suggest that an increase in radial BMD may not be a useful marker of the improvement in bone lesions in ABD patients.

Two chronic dialysis patients with massive ascites caused by cirrhosis were treated by infusion of their ascites directly into the blood circuit. This stabilized their hemodynamics during dialysis, facilitating the control of weight gain and ascites, and thus markedly improving their general condition. Long-term use of this therapy was able to prevent the accumulation of ascitic fluid. Interestingly, fever occurred when this therapy was performed with hemodialysis, but not with hemofiltration or hemodiafiltration, suggesting that a pyrogen in the ascites was removed by filtration.

Patients on continuous ambulatory peritoneal dialysis (CAPD) often have abnormalities of lipid metabolism or coagulation and fibrinolysis, these patients may thus be more susceptible to atherosclerosis than those on hemodialysis. It has been reported that hypercoagulability and hyperfibrinolysis are correlated with abnormalities of lipid metabolism. Therefore, we investigated the effect of a decrease in lipids on the coagulation and fibrinolysis system in CAPD patients with hyperlipidemia who received lipid-lowering therapy.The patients included 5 men and 13 women, with a mean age of 52.5 years. Pravastatin sodium (10 mg/day) and ethyl icosapentate (1800 mg/day) were administered concomitantly for 8 weeks. Lipid levels and coagulation/fibrinolysis parameters were measured before and after therapy. The patients were divided into two groups depending on their response to therapy: responders showed a decrease in total cholesterol or triglycerides by at least 20% and non-responders showed less improvement. In the responders, the levels of protein C, tissue plasminogen activator/plasminogen activator inhibitor-I complex, factor XIII, α2-plasmin inhibitor, and D-dimer were significantly lower after therapy than before therapy. Protein C, factor XIII, and α2-plasmin inhibitor were also significantly decreased after therapy in non-responders, but the extent of the decrease was smaller. The plasminogen level was significantly increased after therapy in non-responders. These findings suggest that a decrease in lipid levels and/or some other action by lipid-lowering agents may correct abnormalities of coagulation and fibrinolysis in CAPD patients. (Int J Artif Organs 2000; 23: 27–32)

Arteriovenous fistula dysfunction is a constant problem in chronic hemodialysis patients. We investigated the factors influencing fistula dysfunction in 184 patients on chronic hemodialysis. Stepwise regression analysis and Cox proportional hazards model were used to assess the relationship between fistula dysfunction and age, sex, duration of hemodialysis, diabetes mellitus, hematocrit, serum creatinine, blood urea nitrogen, KW, prothrombin time, blood pressure, anticoagulant therapy, dose of erythropoietin, calcium channel blocker therapy, and angiotensin-converting enzyme inhibitor therapy. Fistula dysfunction showed a significant relationship with a low systolic blood pressure, a low hematocrit, the presence of diabetes mellitus, and angiotensin-converting enzyme inhibitor therapy. These results suggested that treatment with angiotensin-converting enzyme inhibitors may help to prevent fistula dysfunction.

A 32-year-old male dialysis patient with lupus nephritis was admitted because of shunt obstruction. The arteriovenous fistula was reconstructed, but obstruction recurred twice within several hours after surgery. A high blood level of anticardiolipin β2-glycoprotein I antibody suggested that shunt obstruction was caused by a thrombotic tendency related to the antiphospholipid antibody syndrome. Accordingly, for the third shunt procedure, antiplatelet therapy (which had been commenced for systemic lupus erythematosus) was combined with dalteparin sodium from before surgery and warfarin was added postoperatively. This regimen prevented shunt obstruction. In conclusion, hemodialysis patients who suffer repeated shunt obstruction should be examined for antiphospholipid antibody syndrome.

To perform adequate peritoneal dialysis, it is necessary to individualize the dialysis regimen. PD Adequest is a software program based on the three-pore model that can be used to predict solute clearance and ultrafiltration volume during peritoneal dialysis. We evaluated the ability of this program to predict the solute clearance and ultrafiltration volume in Japanese patients on peritoneal dialysis. The weekly creatinine clearance and weekly urea Kt/V were determined in 45 patients. The PD Adequest was used to simulate their current dialysis regimens and the predicted values of these parameters were calculated. Strong positive correlations were obtained between the actual and predicted weekly creatinine clearance (r=0.993) and weekly urea Kt/V (r=0.991). In conclusion, this program is potentially useful for designing peritoneal dialysis regimens in Japanese patients, even though they have a smaller body mass than Canadians and Americans for whom it was designed.

To evaluate the biocompatibility of dialysis membranes, blood samples were collected from 10 hemodialysis patients immediately before dialysis and peripheral blood mononuclear cells were isolated. The 3.0 x 105cells/ml were then passed 30 times through modules made of a polyethylene glycolgrafted cellulose membrane, a polyacrylonitrile membrane, and a polysulfone membrane. Expression of messenger RNA for tumor necrosi factor-α (TNF-α) was determined. Cells were also cultured for 2 h with and without lipopolysaccharide and TNF-α levels in the supernatant were measured.TNF-α messenger RNA expression was significantly higher immediately after passage through the polyacrylonitrile membrane compared with the other membranes. Cells cultured without lipopolysaccharide, produced significantly less TNF-α after passage through the polysulfone membrane, while lipopolysaccharide significantly increased TNF-α production by cells passed through the polyacrylonitrile membrane. These results suggest that biocompatibility differs even among dialysis membranes believed to cause no complement activation.

Recombinant human erythropoietin (rHuEPO) can dramatically improve anemia in dialysis patients, but about 20% of patients show a poor response to this agent. It has been reported that cytokines, including interleukin (IL)-1ß, may inhibit the maturation of erythrocytes. To investigate the mechanisms of unresponsiveness to rHuEPO, we isolated peripheral blood mononuclear cells from 12 patients on continuous ambulatory peritoneal dialysis who were receiving maintenance rHuEPO therapy for renal anemia. Cells were cultured with rHuEPO and IL-1 ß production was assessed. In the six patients who did not respond to rHuEPO therapy, there was a marked increase in IL-1 ß during culture with rHuEPO. In contrast, the addition of rHuEPO to cultures of cells from the six responding patients caused little increase in IL-1 ß, and there was a significant difference between the two groups. Induction of IL-1 ß by rHuEPO may be one cause of persistent anemia in dialysis patients.

We report on a patient who developed bilateral renal cell carcinoma during continuous ambulatory peritoneal dialysis for chronic renal failure. He was successfully maintained on this type of dialysis after bilateral abdominal nephrectomy.

Tissue factor and tissue factor pathway inhibitor are important in extrinsic coagulation. We investigated their clinical significance in hemodialysis patients. We took blood samples, prior to initiation of routine hemodialysis, from 73 patients on hemodialysis (35 men and 38 women aged 56.1 ± 11.7 years on dialysis for 82.1 ± 61.0 months), and determined tissue factor and tissue factor pathway inhibitor levels by ELISA. In the patients the tissue factor level was 704.5 ± 141.6 pg/ml and the tissue factor pathway inhibitor level was 44.5 ± 23.3 ng/ml; both values were significantly higher than in normal controls (192.7 ± 36.6 pg/ml and 18.6 ± 5.7 ng/ml, respectively). In patients with shunt obstruction, tissue factor pathway inhibitor levels were significantly higher than in those without it. Therefore, the tissue factor pathway inhibitor level may be a marker of shunt obstruction.

We corrected malpositioned continuous ambulatory peritoneal dialysis catheters in six patients using a new technique named the “push-pull method”. A gastric biopsy forceps was advanced through the catheter to near its tip. After manipulating the tip of the forceps through the abdominal wall, the forceps was opened and pulled out slowly. Repeated insertion and removal of the forceps induced the catheter to return to the pelvic cavity. This push-pull method was successful for Swan neck straight (n=2) and coiled (n=4) catheters in all patients. The time required for the procedure was only 5–10 minutes and there were no complications.

A 57 year-old male dialysis patient died soon after the onset of high fever, hypoglycemia, and disturbance of consciousness. Autopsy revealed granulomatous lesions associated with caseous necrosis mainly found in the liver, despite the absence of pulmonary changes on chest radiographs performed during the patients illness. It appears that tubercle bacilli were hematogenously disseminated mainly to the liver causing miliary tuberculosis without producing typical diffuse lesions in the lungs. Since tuberculosis is a common complication in hemodialysis patients, the potential development of atypical miliary tuberculosis should always be borne in mind. (Int J Artif Organs 1998; 21:23–5)

Transverse myelitis (TM) is a very rare complication of systemic lupus erythematosus (SLE) and its prognosis is poor. It therefore needs to be treated aggressively. We describe a patient suffering from SLE associated with TM, who responded well to a combination of immunoadsorption therapy and steroid mini-pulse therapy. His serum interleukin 6 levels as well as clinical indicators fell to normal after this treatment.

Continuous ambulatory peritoneal dialysis (CAPD) is associated with various problems, including damage to the CAPD catheter. We encountered catheter rupture around the titanium adaptor in a patient who had been on CAPD for 7 years. The area near the adaptor generally suffers damage secondary to deterioration of the silicon composing the catheter. However, stereoscopic and electron microscopic observation of the surface of the catheter revealed no deterioration. Instead, there were fine scratches around the site of rupture and the broken surface was rough. Since the patient did not protect the catheter with gauze near the titanium adaptor, it was probably damaged by the adaptor and then ruptured by some external force. (Int J Artif Organs 1998; 21:95–6)