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症例は68歳，男性．主訴は，全身倦怠感，PD排液異常．既往歴に関節リウマチを認める．現病歴：慢性腎不全（原疾患不明）のためSMAP法にてPDカテーテル挿入．その後2006年10月からCAPDにて当院で透析導入．2年9か月のPD歴で，出口部感染や腹膜炎の既往を認めず経過していた．2009年6月X日にエリスロポエチン注射と採血を実施，特に体調不良の訴えもなく帰宅した．後日判明した採血結果でCRPが31.24mg/dLと異常高値を示していた．その前後に腹痛なく，排液混濁も認めなかったが，同年7月10日早朝より「腹痛はないが，突然に透析液の注入途中から肛門より排液する」との訴えで診察依頼があり，独歩にて救急来院した．PDカテーテルから食物残渣を含む混濁した排液を確認，穿孔性腹膜炎を疑い，緊急開腹手術をした．カテーテル周囲で瘻孔形成し，癒着した消化管の剥離に難渋して穿孔部位の同定は困難であった．臨床経過から本症例の穿孔性腹膜炎の機序は次のとおりと推察する．すなわち，憩室炎などを原因にすでに潜在した腹膜炎を約2週間前に発症し，被覆した腸間膜とカテーテルが治癒過程において癒着．その後，機械的刺激によりCAPDカテーテル先端が脆弱箇所を穿通し，腸管内に迷入した．PD患者の穿孔性腹膜炎の診断はしばしば困難である．その理由に，(1)free airや腹水が消化管穿孔の根拠になりにくいこと，(2)腹膜透析液による洗浄効果で腹膜刺激症状が緩和されること，(3)通常のPD腹膜炎との鑑別が困難であること等があげられ，高い死亡率の原因となっている．穿孔性腹膜炎の死亡率が高いことから臨床上，極めて危険な合併症であるといえる．腹膜透析液による洗浄効果で腹膜刺激症状が緩和されるなど発見が遅れる可能性があることを留意し，排液の詳細な観察ならびに炎症所見などのデータの推移には十分注意する必要があると思われた．

Background: Low-density lipoprotein (LDL) apheresis is effective in the treatment of peripheral arterial occlusive disease (PAOD). In the present study, we attempted to determine whether LDL apheresis is effective even for PAOD patients undergoing hemodialysis, who tend to be refractory to any treatment, and if so, to determine the mechanism of its efficacy. Methods: Serum levels of lipids and vascular growth factors, leg symptom, and endothelium-dependent vasodilation were investigated before and after 10 sessions of LDL apheresis in 11 PAOD patients undergoing hemodialysis. Results: Serum levels of total cholesterol, LDL cholesterol, and triglyceride exhibited drastic reduction, which completely disappeared 4 weeks after the final apheresis. Resting leg pain was improved in 6 cases even 4 weeks after final apheresis. Endothelium-dependent vasodilation was significantly increased 4 weeks after final apheresis (1.6 ± 0.6 to 4.7 ± 1.0%, p < 0.05). Levels of vascular growth factors, hepatocyte growth factor and vascular endothelial growth factor were not changed during treatment. Conclusions: These findings suggested that LDL apheresis is effective even in PAOD patients undergoing hemodialysis. Our findings suggest that its mechanisms of efficacy include improvement of vascular endothelial dysfunction, in addition to drastic but acute reduction of lipid levels. Since PAOD patients undergoing hemodialysis tend to be resistant to any treatment and are at high risk for lower-extremity amputation, LDL apheresis could be a useful strategy for treatment of them.

We report a normomagnesemic patient with low normal blood pressure, hypokalemic alkalosis, hyperreninemia, hyperaldosteronism, and hypocalciuria. In renal clearance studies, distal delivery increased well and fractional distal solute reabsorption was dramatically diminished after the administration of furosemide, whereas thiazide produced no change in distal delivery and a moderate decrease in fractional distal solute reabsorption. These findings suggested that there may have been a defective locus in some part of the thiazide-sensitive segment of the distal convoluted tubule. As the features in this patient appear to be similar to those in Gitelman's syndrome, it is appropriate to designate this case, characterized by lack of hypomagnesemia, as a subgroup of Gitelman's syndrome.

We have been conducting a 1-week educational admission program for patients at the conservative phase of chronic kidney disease (CKD) since 2006. In this study we evaluated the effect of the program.We retrospectively reviewed 469 patients who could be followed for 12 months after a 1-week educational admission program for CKD out of a total of 700 patients who attended the program between October 2006 and April 2012. We compared the rates of decrease in renal function before and after the program. In addition, we divided the patients into two groups of diabetic nephropathy and non-diabetic nephropathy. We compared the rate of decrease in renal function in each group.The rate of decrease in renal function 12 months after discharge was improved compared with that 6 months before admission. (before: 0.316 mL/min/1.73 m2/month; after: 0.001 mL/min/1.73 m2/month.) The rate of decrease in renal function 6 months before admission of the diabetic nephropathy group was 72.3 times faster than that of the non-diabetic nephropathy group. However, the rate of decrease in renal function 12 months after admission was improved in both groups.It was revealed that the educational admission program is effective for preserving the renal function on patients at the conservative phase of CKD.

A 53-year-old woman was admitted to our hospital due to abdominal pain, diarrhea, and shunt occlusion caused by dehydration. She had undergone hemodialysis due to diabetic nephropathy over a ten-year period. She was hospitalized again with fever and a persistent high serum CRP level. We started antibiotic administration using cefotiam hexetil hydrochloride because of ascites and peritoneum thickening observed by abdominal computed tomography. Although her symptoms, such as abdominal pain and diarrhea, improved after the administration of antibiotics, the ascites and the peritoneum thickening did not improve. On the fourth hospital day, we attempted ascites aspiration to investigate the etiology of the peritonitis. Cytological examination suggested tuberculous peritonitis because of predominant macrophage cell proliferation, a high level of ADA concentration, and a high level of CA125 of ascites. Although QuantiFERON-tuberculosis (QFT) and the Gaffky scale were negative, we started multidrug therapy (isoniazid + rifampicin + pyrazinamide + ethambutol) on the 20th hospital day. She was finally diagnosed as mycobacterium tuberculous peritonitis based on biopsy of the tissue of the ileum and the results of colonoscopy. Administration of antituberculosis chemotherapy improved abdominal fullness and ascites and the patient was discharged on the 97th hospital day. Moreover Kuno et al. reported that serum soluble interleukin-2 receptor(sIL-2R) and CA-125 levels can be used to monitor the response to anti-tuberculosis treatment. In this case, we use these markers to monitor the response to treatment. We experienced a case of tuberculous peritonitis undergoing hemodialysis. Tuberculosis should be suspected when patients undergoing dialysis have long-term fever of unknown etiology. There are many reports stating that the sensitivity and specificity of QuantiFERON-tuberculosis (QFT) and sputum culture are low in latent tuberculosis infection of dialysis patients. Accordingly it is necessary to diagnose mycobacterium tuberculous peritonitis comprehensively by the clinical symptoms and image analysis.

慢性腎不全にて血液透析中の36歳の男性に合併した間質性肺炎 (BOOP) の1例を報告する. 労作時呼吸困難を主訴とし, 胸部X線写真で右上中肺野および左上肺野に浸潤影を認めた. 胸部CT写真では, 気管支透亮像を伴う濃度上昇域を認めた. 気管支肺胞洗浄液検査では, 総細胞数の増加, リンパ球分画の増加, OKT4+/OKT8+の低下を認めた. BOOPの可能性が高いと考えられた. 抗菌薬に対する反応性は乏しく, 副腎皮質ステロイドが著効した. 抗菌薬の反応が乏しい胸部浸潤影を認める透析患者においては, BOOPの存在も考慮に入れて治療することが必要と考えられた.

長期透析患者の腎性骨異栄養症 (ROD) 特に二次性副甲状腺機能亢進症に対するvitamin D3と炭酸Caを投与した上にelcatonin®を併用してその有効性を骨シンチグラフィーによる定量的評価とDEXA法による骨密度により検討した. 対象は週3回血液透析をうけAL-Pが10 KAU以上で骨関節痛を訴える患者を選んだ. 活性型vitamin D3の投与量を各患者で一定とし炭酸Caの投与量により血清Ca値が9-11mg/dlになるように調整した.骨シンチグラフィーを行い視覚的分類にて二次性副甲状腺機能亢進症のパターンを示す症例12名を対象とした. elcatonin®投与群 (ECT群) の7例には透析毎に80単位のelcatonin®を6か月間点滴静注し, 残りの5例は対照群として比較検討した. HS-PTHと血中free hydroxyproline (OH-Pro) 値は両群とも高値であり, この研究期間中変化なく推移した. ECT群でAL-P値と酒石酸耐性酸性フォスファターゼ (TRACP) 値は低下し, DEXA法による腰椎骨密度 (L2-4 BMD) は有意 (p

A 27-year-old woman was referred to our hospital because of pancytopenia and nephritic syndrome in November, 2008. The findings of physical and laboratory examinations showed systemic lupus erythematosus (SLE). Diffuse proliferative lupus nephritis(group IV-G(A))was confirmed by renal biopsy. After combined therapy with prednisolone, intravenous cyclophosphamide pulse and mizoribine, proteinuria decreased from 13.0 g/day to 2.0 g/day and the serum complement level recovered to the normal level. However, she visited our hospital again for management of bleeding tendency in July 2009. She was diagnosed as hemophagocytic syndrome (HPS), with pancytopenia, high ferritin, high LDH level and hemophagocytosis in the bone marrow. She was treated effectively with steroid pulse therapy, but relapsed with HPS after two weeks. Although her child caught a cold, the case did not show any sign or symptom of infection, such as the common cold. However, we diagnosed her HPS as infection-associated hemophagocytic syndrome (IAHS) because she was not in the active phase of SLE at the onset of hemophagocytosis and the laboratory findings showed elevation of her serum ferritin and LDH. Therefore, we considered that her infectious sign may have been concealed by immunosuppressive therapy with prednisolone for SLE. It is very difficult to distinguish between IAHS and autoimmune-associated hemophagocytic syndrome (AAHS)in autoimmune diseases, but the differential diagnosis is necessary to treat the HPS. Here, we report an important case of HPS complicated with SLE. This case may attract interest particularly in the management of HPS-complicated autoimmune disease. Therefore, we report it with a review of the literature.

新規透析導入患者32名 (男17, 女15), 維持透析患者118名 (男69, 女49), 健常人43名 (男22, 女21) の遊離型T4 (FT4) を平衡透析法に基づくラジオイムノアッセイキットで測定し, 従来の標識アナログT4を用いる方法と比較検討した. アナログ法では導入期32名中16名 (50%), 維持期118名中34名 (29%) が正常範囲に分布したが平衡透析法ではそれぞれ32名中29名 (91%), 118名中98名 (83%) が正常範囲に分布した. 平衡透析法ではFT4とアルブミン, TBG濃度との間に有意な関係は認めなかった. 平衡透析法とアナログ法の間にはr=0.636と正の相関関係を認めたが平衡透析法において高値に測定された. 橋本病による甲状腺機能低下症を合併した透析患者および透析患者に合併したヨード蓄積による-過性可逆性甲状腺機能低下症患者の臨床経過中のFT4濃度を検討したが平衡透析法はアナログ法に比し, TSHの分泌や病態を明瞭に反映した. 以上より, 平衡透析法による透析患者の血中FT4の測定は甲状腺機能の評価や臨床経過のモニタリングに有用と考えられた.

A 72-year-old woman developed common cold-like symptoms, diarrhea, a staggering gait, and persistent anorexia from the beginning of May 2009. In the middle of May, her general fatigue worsened, and she was transported to our hospital by ambulance. Abdominal CT showed bilateral renal enlargement, and her general condition and renal function rapidly deteriorated. The soluble interleukin-2 receptor (sIL-2R) level was elevated to 5,928 U/mL, and gallium scintigraphy showed a weak uptake in both kidneys. We considered the possibility of malignant lymphoma, and performed a renal biopsy, which showed no glomerular abnormalities, but disclosed the accumulation of large, atypical lymphoid cells with a high N/C ratio and dark chromatin in peritubular capillaries (PTC). On immunohistochemical staining, these atypical cells were found to be CD5(+), CD20 (+/-), CD10(-), CD3(-), and CD7(-), leading to a diagnosis of intravascular large B-cell lymphoma (IVLBCL). Since gallium scintigraphy showed no uptake in other organs, and examination of the cerebrospinal fluid and bone marrow revealed no tumor cells, the patient was considered to have kidney-limited IVLBCL. Chemotherapy was started immediately, which resulted in an improved general condition. Although her renal function deteriorated sufficiently to require dialysis, she was weaned from dialysis. After treatment with chemotherapy, the enlarged kidneys returned to the normal size. Subsequently, she has been receiving chemotherapy intermittently, and has remained free of recurrence. In general, IVLBCL mainly involving the kidney is difficult to diagnose antemortem, and is sometimes found at autopsy. We suggest that bilateral renal enlargement with renal failure of unknown origin should raise the suspicion of malignant lymphoma requiring a prompt renal biopsy. Cases of LBCL in which lymphoma cells fill PTC, as in this patient, have rarely been reported. We believe that this case is extremely valuable in understanding the pathogenesis of intravascular lymphoma invading the kidney; therefore, we report it with a review of the literature.

A 38-year-old female developed pain in the right leg in 2006. In 2007, the diagnosis of femoral head necrosis was made based on MR images, and femoral head prosthetic replacement was performed. In April 2009, she visited a local hospital for low back pain, and was referred to our department due to electrolyte abnormalities on hemanalysis. Since marked hypokalemia (K=2.5 mEq/L), hypophosphatemia, hyperchloric metabolic acidosis, proteinuria, and urinary blood sugar suggested Fanconi syndrome, she was admitted for close examination. Bone survey showed a marked decrease in the amount of bone particularly in the four limbs and fracture at the proximal 1/3 of the left ulnar bone. In the lumbar spine, scoliosis and vertebral deformity were observed. Since impaired P re-absorption and unselected aminoaciduria and osteomalacia were also present, the diagnosis of Fanconi syndrome was made. On admission, ventricular tachycardia developed due to hypokalemia, requiring immediate electrolyte correction. For differentiation from acquired Fanconi syndrome, various examinations were performed. No apparent cause was found except for the positive antimitochondrial antibody-M2 (anti-M2). In this case, no data suggested liver dysfunction, and subsequent liver biopsy also showed no significant pathological findings pointing to PBC. We encountered a patient with Fanconi syndrome positive for anti-M2. This case may attract interest, particularly in the mechanism of nephropathy due to anti-M2, and therefore, this case is reported with a literature review.

A multicenter cooperative study was designed to evaluate the efficacy and safety of FR-860 as an anticoagulant in hemodialysis. Sixty-five stable maintenance hemodialysis patients were enrolled into the study from fourteen institutions in Japan. 4 cases were excluded from the efficacy analysis because of protocol deviation (a violation of the concomitant drugs). The period of the study was fixed at two weeks. Dosage requirements were 15.0-20.0 anti-Xa units/kg as a bolus and 7.5-10.0 anti-Xa units/kg/hr for continuous hourly administration. Total dosage of FR-860 (F) was 2, 505±127 anti-Xa units compared to that of a conventional heparin (CH) dose of 6, 124 ±190 units. No difference in the residual blood in the extracorporeal circuit was observed between the F and CH groups. The hemostatic time at the puncture site after the completion of dialysis was significantly shortened in the F group (7.9±0.7 min) in comparison with the CH group (11.4±1.1 min; p

It is known that the angiotensin receptor blockers (ARBs) have organ protective effects in patients with heart failure or renal impairment. Several studies have revealed that the ARB telmisartan has an organ protective effect, but there have been few studies directly comparing the effects of telmisartan and calcium antagonists, since most clinical studies on telmisartan have been conducted in treated patients or patients on combination therapy. The present study was conducted to compare the renal and vascular protective effects of telmisartan monotherapy and calcium antagonist monotherapy in untreated hypertensive patients. Forty-three patients with untreated essential hypertension were randomized to receive amlodipine (n=22) or telmisartan (n=21), which were respectively administered at doses of 5 mg and 40 mg once daily in the morning for 24 weeks. The patients were examined before and after treatment to assess changes of renal function, flow-mediated dilation (a parameter of vascular endothelial function), and brachial-ankle pulse wave velocity (baPWV; a parameter of arteriosclerosis). Before treatment, there were no significant differences in these parameters between groups. The decreases of urinary albumin excretion and baPWV, and the increase of flow-mediated dilation were significantly greater in the telmisartan group than the amlodipine group, while the antihypertensive effects were not significantly different between the two groups. In conclusion, these results suggest that telmisartan is more effective at protecting renal function and vascular endothelial function, and at improving arteriosclerosis than the calcium channel blocker in patients with essential hypertension.

It is generally recognized that Antithrombin III plays an important role as an inhibitor on the coagulation mechanism of the blood and is known to be decreased in its amount on the cases of myocardial infarction or arteriosclerosis, in the meanwhile the arteriosclerosis has been considered to be one of thrombogenic factors. This research was designed to investigate the effects of Antithrombin III on the relationship between thrombosis and atherosclerosis. For the purification of Antithrombin III, heat defibrinated plasma was applied to the column of heparin covalentry linked to Sepharose 4B. Non-specifically bound protein was eluted with 0.01M Tris HCl buffer pH 7.5 containing 0.3M NaCl and Antithrombin III subsequently eluted with 0.01M Tris HCl buffer containing 0.08M NaCl. Aliquots of each fractions were assayed for antithrombin activity. The highly purified Antithrombin III was obtained by this affinity chromatography with heparin as the legand. This inhibitor possessed both heparin cofactor and progressive antithrombin activity, and SDS disc electrophoresis showed only single band of molecular weight 62, 000 daltons and rabbit antiserum immunized with this fraction showed also single precipitation arc on IEP. The degree of lipolytic activity was measured by estimation of amount of the released free fatty acids according to the modified method of Boberg and Carlson. The incubation mixture contained various triglycerides as substrates and Antithrombin III as enzyme. The triglyceride substrate, Intralipid fat emulsions were hydrolyzed by the purified Antithrombin III to a certain extent and free fatty acids released were increased pararell with the incubation period and with Antithrombin III amount. The effects of Antithrombin III on the various triglyceride substrates were compared and the triglyceride moiety of these substrates were preferentially hydrolyzed in order of Intralipid, Triolein, Serum Chylomicron.Atherosclerosis is one of the thrombogenic factors and has been considered to be due to the disorders of lipid metabolism on the vessel wall and also hyperlipemia is emphasized to be one of causative factors. On the other hand decreased antithrombin activity developes hypercoagulable state, which results in fibrin formation on the endothelial cells. Present data indicates that Antithrombin III with lipolytic activity could be postulated as an important inhibitor which intervenes between thrombosis and arteriosclerosis.

The major part of orally administered β-pyridylcarbinol was converted to nicotinic acid in the gastrointestinal tract, whereas that administered intraperitoneally was partially converted to nicotinic acid in the liver. The conversion of this compound to nicotinic acid in both the gastrointestinal tract and liver involved enzymatic processes. The converted nicotinic acid from β-pyridylcarbinol may play a dominant role in the biological actions of β-pyridylcarbinol and possibly involves in the synthesis of NAD via Preiss-Handler's pathway.

Effects of anticonvulsants were determined on thalamic afterdischarge in gallamine-immobilized cats and d-tubocurarine-immobilized rats in order to clarify the participation of anticonvulsants in the thalamus. Thalamic afterdischarge was induced by electrical stimulation of cat nucleus centralis lateralis and rat nucleus reticularis at 50 Hz, 1 msec for 4 sec. In cats, diphenylhydantoin, carbamazepine, phenobarbital, and diazepam raised afterdischarge threshold, and shortened its duration induced at twice the threshold voltage. Trimethadione and dipropylacetate raised the threshold, but did not change the duration. In rats, diphenylhydantoin, phenobarbital, and diazepam raised the threshold, and shortened the duration with comparable dose ranges used for cats. Dipropylacetate and acetazolamide raised the threshold, although did not change the duration except for shortening action with a higher dose of dipropylacetate. Trimethadione was without effect. These results suggest that the depressive effect of anticonvulsants on the thalamus is, at least in part, associated with control of the epilepsies.

血液透析療法の確立により, 慢性血液透析患者の長期生存が可能となるにつれ, 種々合併症が問題とされている.この1つとして, 慢性血液透析患者に認められる不規則抗体について検討することを目的とした. スクリーニング法には食塩水法, アルブミン法, 抗グロブリン法, ブロメリン法を併用し, 血液透析導入前, 導入後は3-6か月ごとにスクリーニングを行い, 不規則抗体の存在する場合には同定検査を行った.その結果, 全く輸血歴がなく, 臨床症状もない2名の慢性血液透析患者に不規則抗体を検出した. 症例1は抗HI抗体であり, 抗体価は2倍であった. また, 患者の血液型はA1, Rh1rh (CcDee), NNss, Le(a+b-), P2で, 直接抗グロブリン試験は陰性であった. さらに, 成人O群赤血球を用いた寒冷凝集反応が32倍であることから, 本患者に検出された不規則抗体は抗HI特異性をもつ寒冷凝集素と考えられた.症例2は抗P1抗体で, 抗体価は2倍であった. また, 患者の血液型はA1, Rh1Rh1 (CCDee), MMss, Le(a-b-), P2で, 直接抗グロブリン試験は陰性であった.本邦では慢性血液透析患者に不規則抗体が認められたとの報告はきわめて少ない. しかし, 著者らの検討では慢性血液透析患者では従来, 最も不規則抗体が高頻度に認められるとされている経産婦群より高い. しかも, 慢性血液透析患者に不規則抗体が存在する場合, 患者が将来, 輸血, 手術, 腎移植等に遭遇する機会を考慮すると, 臨床上, きわめて重要な意義をもつことが予想される.以上から, 慢性血液透析患者では不規則抗体のスクリーニングの必要性が痛感される.