Search

Dialysis-related amyloidosis is a serious complication of long-term hemodialysis. Its pathogenic mechanism involves accumulation of β2-microglobulin in the blood, which then forms amyloid fibrils and is deposited in tissues, leading to inflammation and activation of osteoclasts. Lixelle, a direct hemoperfusion column for adsorption of β2-microglobulin, has been available since 1996 to treat dialysis-related amyloidosis in Japan. However, previous studies showing the therapeutic efficacy of Lixelle were conducted in small numbers of patients with specific dialysis methods. Here, we report the results of a nationwide questionnaire survey on the therapeutic effects of Lixelle. Questionnaires to patients and their attending physicians on changes in symptoms of dialysis-related amyloidosis by Lixelle treatment were sent to 928 institutions that had used Lixelle, and fully completed questionnaires were returned from 345 patients at 138 institutions. The patients included 161 males and 184 females 62.9 ± 7.7 years age, who had undergone dialysis for 25.9 ± 6.2 years and Lixelle treatment for 3.5 ± 2.7 years. Based on self-evaluation by patients, worsening of symptoms was inhibited in 84.9-96.5% of patients. Of the patients, 91.3% felt that worsening of their overall symptoms had been inhibited, while attending physicians evaluated the treatment as effective or partially effective for 72.8% of patients. Our survey showed that Lixelle treatment improved symptoms or prevented the progression of dialysis-related amyloidosis in most patients.

Questionnaire forms for an annual survey conducted at the end of 2001 were sent out to 3520 institutions, and 3485 replies were received (response rate, 99.00%). According to the survey, the dialysis population of Japan at year end was 219 183 patients, up 6.3% (13 049) over the year before. This equals 1721.9 dialysis patients per million population. The gross mortality rate was 9.3% for the year extending from the end of 2000 to the end of 2001. The mean age of patients beginning dialysis was 64.2 years (+/- 13.7 SD). The mean age of the overall dialysis population in the study year was 61.6 years (+/- 13.1 SD), which was also a higher age than the year before. Among dialysis patients, the primary disease was diabetic nephropathy in 38.1% of patients, slightly down from 39.1% the previous year. Chronic glomerulonephritis was the primary disease in 32.4% of cases, a decrease from 34.7% the previous year. This survey included for the first time the items of the lowest blood pressure during hemodialysis session, vasopressor therapy before dialysis and vasopressor therapy during dialysis session. An analysis of the relationship between the type of vascular access used at the initiation of dialysis and the survival prognosis revealed a significantly higher risk of death in patients undergoing dialysis with synthetic arterio-venous (AV) fistula, AV shunt, or catheter implantation into a central vein than in those receiving dialysis treatments with a native fistula. There was a significantly lower risk of death in the patient group in whom the vascular access was created at 3-6 months before initiation of dialysis than in those in whom such access was created at the time of initiation or within 3 months before the initiation of dialysis. An analysis of the risk factors affecting survival prognosis in maintenance hemodialysis patients showed that risk factors for death are post-dialysis systolic blood pressure over 180 mm Hg and lower than 120 mm Hg, blood pressure elevating progressively from the start to the end of dialysis, serum high density lipoprotein cholesterol concentration of less than 30 mg/dL, and a higher ultrafiltration rate. In comparisons of the death risk between the patient group with a history of intervention for ischemic heart disease and the patient group with a history of myocardial infarction or heart failure but without such intervention, among diabetes patients, those who underwent percutaneous transluminal coronary angioplasty had a significantly lower risk of death than those in whom no intervention was made.

We examined the incidence rates of psychiatric disorders in end-stage renal failure patients on hemodialysis (HD) based on 4-year long-term follow-up. Among various psychiatric disorders, the frequency of three psychiatric disorders, dementia, delirium, and major depression, was relatively high. One-year incidence rate of whole psychiatric disorders was 10.6% (7.1% in non-aged and 13.7% in aged). One-year incidence rate of dementia in aged patients was 4.2% (dementia of the Alzheimer’s disease, 0.5%; multi-infarct dementia, 3.7%). One-year incidence rate of multi-infarct dementia in aged HD patients was 7.4 times as large as that in the elderly general populations, suggesting that aged HD patients tend to exhibit multi-infarct dementia. The high incidence rate may be closely related to advanced arteriosclerosis and other medical conditions. Psychiatric management is required for ESRD patients with three major psychiatric disorders, dementia, delirium, and major depression, in particular for aged patients with multi-infarct dementia who has received long-term HD therapy.

Background: The introduction of erythropoietinn stimulating agent (ESA) in clinical practice has completely altered the management of patients with chronic kidney disease. However, the successful correction of anemia has not always resulted in improvement of mortality in CKD patients. One of the main reasons for failure of preservation of renal function is excessive elevation of hemoglobin (Hb) levels for CKD patients. This indicates the need for maintaining appropriate target levels of Hb to preclude the progression of CKD. The aim of this study was to compare the effects of two Hb levels on progression of CKD patients in a 2 year period. Subjects: A total of 167 patients with chronic kidney disease (2mg

A statistical survey at the end of 1999 by the Japanese Society for Dialysis Therapy resulted in responses from 3, 220 (99.66%) of 3, 231 institutions providing dialysis. The survey found 197, 213 chronic dialysis patients in Japan, an increase of 6.4% (11, 891 patients) from the 1998 survey. The 1999 survey found a slight decrease in the gross annual mortality percentage compared to 1998 (9.7%). The mean age of patients newly introduced to dialysis increased to 63.4±13.9 (±SD) years in 1999. The mean age of the dialysis population at the end of 1999 was 60.6±13.3 years. The primary diseases leading to dialysis were diabetic nephropathy (36.2%) and chronic glomerulonephritis (33.6%).New survey items for 1999 survey included the following: 1) with/without reverse osmosis, 2) with/without dialysate endotoxin measurement and endotoxin concentration, 3) itchiness, 4) HBs and HBe antigen/antibody, 5) earlier hepatitis B vaccine inoculation, 6) HCV antibody/HCV-RNA, 7) serum glutamic pyruvic acid transaminase (GPT) activity, 8) hepatocellular carcinoma or cirrhosis, 9) previous limb amputation, 10) history of cerebral infarction, cerebral hemorrhage, or myocardial infarction, 11) loss of eyesight due to diabetic retinopathy or retinal circulatory disturbance, 12) serum cholesterol level, 13) number of cigarettes smoked, 14) platelet and leukocyte counts, 15) C-reactive protein levels, 16) height and body mass index (BMI), 17) tuberculosis within the previous year and 18) both the fluid substitution method in hemodiafiltration and the amount of substitution fluid.The survey findings for 1999 included 1) 93.0% of the patients were dialyzed using reverse osmosis 2) endotoxin concentrations tended to be lower in institutions with more patients, and 3) 56.7% of the patients experienced no itchiness and received no treatment for itchiness. Other survey findings were that 84.7% of the patients were HBs antigen (-) antibody (-), 1.9% were HBs antigen (+) antibody (-), and 13.0% were HBs antigen (-) antibody (+). The survey also found that 2.3% of patients were inoculated with Hepatitis B vaccine, 16.1% were HCV antibody (+), and 8.2% were HCV-RNA (+). The survey found that 2.1% of the patients had cirrhotic complications and 0.6% had hepatocellular carcinoma. The mean serum total cholesterol level was 162.84mg/dl, and the mean BMI was 20.61kg/m2. Using the Cox's proportional hazards model, a Kt/V of 1.4, a normalized protein catabolic rate of less than 0.9g/kg/day or more than 1.5g/kg/day, and a low creatinine generation rate were risk factors in the 6-year mid-term prognosis for hemodialysis patients.

Dialysis-related amyloidosis is a serious complication of long-term hemodialysis. Its pathogenic mechanism involves accumulation of β2-microglobulin in the blood, which then forms amyloid fibrils and is deposited in tissues, leading to inflammation and activation of osteoclasts. Lixelle, a direct hemoperfusion column for adsorption of β2-microglobulin, has been available since 1996 to treat dialysis-related amyloidosis in Japan. However, previous studies showing the therapeutic efficacy of Lixelle were conducted in small numbers of patients with specific dialysis methods. Here, we report the results of a nationwide questionnaire survey on the therapeutic effects of Lixelle. Questionnaires to patients and their attending physicians on changes in symptoms of dialysis-related amyloidosis by Lixelle treatment were sent to 928 institutions that had used Lixelle, and fully completed questionnaires were returned from 345 patients at 138 institutions. The patients included 161 males and 184 females 62.9 ± 7.7 years age, who had undergone dialysis for 25.9 ± 6.2 years and Lixelle treatment for 3.5 ± 2.7 years. Based on self-evaluation by patients, worsening of symptoms was inhibited in 84.9-96.5% of patients. Of the patients, 91.3% felt that worsening of their overall symptoms had been inhibited, while attending physicians evaluated the treatment as effective or partially effective for 72.8% of patients. Our survey showed that Lixelle treatment improved symptoms or prevented the progression of dialysis-related amyloidosis in most patients.

長期透析患者の妊娠, 分娩の1例を経験したので報告する. 症例は透析歴8年の34歳の女性. 妊娠5週にて当院産婦人科受診, 同時に切迫流産と診断され入院となった. 入院後は腎センターにおいて透析を行った. 透析時間は, BUN60mg/dl, Cr8mg/dl以下を目標に, 妊娠の経過とともに週12時間より最終的には27時間まで延長した. 貧血についてはエリスロポエチン製剤の使用により, Ht30%前後に維持可能であった. また, 妊娠15週より子宮収縮抑制の目的でβ-stimulantを使用した. 特に妊娠21週からは塩酸リトドリンの持続静注に変更し, さらに24週より硫酸マグネシウム (MgSO4) の持続静注も併用し, 妊娠を32週まで継続することができた. 特に重篤な合併症を起こすことなく, 妊娠32週で帝王切開を施行し, 1,700g, Apgar score 7点の男児を出産した.透析患者の妊娠では, 流早産が高頻度でおこるとされているが, 我々は腎不全では使用し難いといわれている子宮収縮抑制剤を長期にわたり使用して妊娠の継続に成功した. 腎機能障害下における塩酸リトドリンとMgSO4の使用法に関し, 文献的考察を加えて報告した.

日本の慢性透析患者の高齢化の実態を明らかにしその要因をさぐるため, 日本透析療法学会統計調査委員会が年度末に行っている全透析施設に対するアンケート調査の1980年から1990年の報告を集計分析した.慢性腎不全による透析導入患者の平均年齢は10年間で9.8年, 透析患者平均年齢は9年間で8.3年高齢化した. その要因として, 日本人母集団の老化のみならず, (1) 透析導入にいたった原疾患が10年間で慢性糸球体腎炎は約2/3から1/2へ減少, 糖尿病は約1/10から1/4に増加, 腎硬化症は軽度増加したこと, (2) 小児の透析導入数および患者数は10年間で1/3以下に減少したこと. (3) 長期透析患者が増加したこと, (4) 徐々にではあるが腎移植が行われ, 若年者が透析を離脱すること, などが挙げられた.このような透析患者の高齢化に伴い, 適切な医療・社会援助システムを構築・整備することが必要である.

Urea index (UI) を透析量の指標に, ハイパフォーマンス膜透析器 (HPM) を用いた短時間biofiltration (BF) を最大6か月間継続し, 各種溶質の治療前血清濃度の推移, 治療中の臨床症状について従来の透析器 (OD) を用いた重炭酸透析 (BCHD) を対照に検討した. また同-のHPMを用いた血液透析とBFの各溶質除去効果についても比較検討した. 対象は1回4-5時間, 週3回のBCHDを行っている安定期透析患者5名で, BFではNa濃度を140mEq/lに調整した重炭酸透析液のA液のみを透析液に用い, 置換液は等張重炭酸Na液 (ジュータミン®) を1.9l/h, 後希釈法で使用した. 治療時間はBCHD時のUIを保持するよう血液流量を調整し設定, 4.3±0.3 (BCHD) から3.3±0.3時間 (BF) に短縮させた. BF変更前後の治療前血清溶質濃度の推移では, HCO3は変更前18.1±2.5から22.6±2.6mEq/l, β2-microglobulin (β2-MG) は60.0±8.5から45.0±10.6mg/lと, BF変更後HCO3は有意の上昇, β2-MGは有意の低下を示し, 他の溶質には変化はみられなかった. 治療中の症状と処置は, 発生頻度, 程度, 処置回数等をindex化し定量的に比較したが, 変更前後で差は見られなかった. 同-HPMを用いたBCHDとBFで溶質除去効果を比較すると, BFがリン (P), β2-MGの除去率で有意の高値を示したものの, 除去量ではすべての溶質でBCHD, BF間に差は認められなかった. UIを指標として設定した短時間BFは, 最大6か月間の治療においても同-UIのBCHDをしのぐ十分な治療効果を示し, 治療時間短縮による不均衡症候群の増悪も認められなかった. また, 治療時間を短縮しても同-のHPMを用いたBCHDと同等の溶質除去効果が得られた. 以上よりUIは短時間治療の至適条件を設定する有用な指標で, BFは治療時間短縮のための有効な手段と考えられた.

A statistical survey of 3932 nationwide hemodi- alysis (hereafter, dialysis) facilities was carried out at the end of 2004, and 3882 facilities (98.73%) responded. The population undergoing dialysis at the end of 2004 was 248 166, an increase of 10 456 patients (4.4%) from that at the end of 2003. The number of dialysis patients per million people was 1943.5. The crude death rate of dialysis patients from the end of 2003 to the end of 2004 was 9.4%. The mean age of patients who underwent dialysis in 2004 was 65.8 years, and that of the total dialysis population was 63.3 years. The percentage distribution of patients who underwent dialysis according to a newly underlying disease showed that 41.3% of patients had diabetic nephropathy and 28.1% had chronic glomerulonephritis. The frequency of calcium carbonate use for dialysis patients was 75.1% and that of sevelamer hydrochloride use was 26.2%. The frequency of sevelamer hydrochloride use does not neces- sarily have a strong correlation with the dose of calcium carbonate. Patients who received high doses of sevelamer hydrochloride tended to have a low concentration of arte- rial blood HCO 3- . Approximately 15% of dialysis patients used an intravenous vitamin D preparation, generally max- acalcitol. The longer the patients had been on dialysis, the higher the frequency of use of an intravenous vitamin D preparation. When the concentration of serum intact par- athyroid hormone (PTH) was more than 200 pg/mL, the frequency of use of an orally administered vitamin D pre- paration decreased; but that of intravenous vitamin D preparation increased. The percentage of dialysis patients who received percutaneous ethanol injection therapy (PEIT) was 1.4%. The percentage was more than 50% in the patients who had been on dialysis for more than 10 years. The percentage of patients who received PEIT again was 35.0%. The percentage of patients who had been on hemodialysis for more than 10 years and received PEIT again was more than 50%. Key Words: Calcium carbon- ate, Death rate, Intact parathyroid hormone, Sevelamer hydrochloride.

A statistical survey of 3750 nationwide dialysis facilities was carried out by the Japanese Society for Dialysis Therapy (JSDT) at the end of 2003, with answers to the questionnaires received from 3717 facilities (99.12%). The population of dialysis patients in Japan at the end of 2003 was 237,710, and the number of dialysis patients per million people was 1862.7. The crude death rate during a 1-year period from the end of 2002 to the end of 2003 was 9.3%. The mean age of patients newly introduced to dialysis was 65.4 years, and the mean age of the entire dialysis population was 62.3 years. The primary diseases in the patients newly introduced to dialysis in 2003 included diabetic nephropathy (41.0% of patients) and chronic glomerulonephritis (29.1% of patients). The mean serum neutral fat concentration for all the dialysis patients was 113.9 +/- 71.7 mg/dL (+/- SD). The mean serum low density lipoprotein (LDL)-cholesterol concentration was 90.8 +/- 30.9 mg/dL. Dialysate calcium concentrations ranging from 3.0 mEq/L to less than 3.5 mEq/L were used for majority of the dialysis patients (55.4%). Among anticoagulants given to the dialysis patients, heparins were the most commonly used in 79.3% of the dialysis patients. The relationship between blood pressure during dialysis and life expectancy for 1 year was analyzed for 43,465 patients who had undergone dialysis three times per week at the end of 2001. Results showed a significantly high mortality risk for patients who had systolic blood pressure of less than 100 mm Hg at the start of dialysis, systolic blood pressure of less than 100 mm Hg at the end of dialysis, and the greatest decrease (lowest) in systolic blood pressure of less than 120 mm Hg during dialysis. Patients who received vasopressor therapy during dialysis had a higher mortality risk than those who received no vasopressor therapy.

Questionnaire forms for an annual survey conducted at the end of 2001 were sent out to 3520 institutions, and 3485 replies were received (response rate, 99.00%). According to the survey, the dialysis population of Japan at year end was 219 183 patients, up 6.3% (13 049) over the year before. This equals 1721.9 dialysis patients per million population. The gross mortality rate was 9.3% for the year extending from the end of 2000 to the end of 2001. The mean age of patients beginning dialysis was 64.2 years (+/- 13.7 SD). The mean age of the overall dialysis population in the study year was 61.6 years (+/- 13.1 SD), which was also a higher age than the year before. Among dialysis patients, the primary disease was diabetic nephropathy in 38.1% of patients, slightly down from 39.1% the previous year. Chronic glomerulonephritis was the primary disease in 32.4% of cases, a decrease from 34.7% the previous year. This survey included for the first time the items of the lowest blood pressure during hemodialysis session, vasopressor therapy before dialysis and vasopressor therapy during dialysis session. An analysis of the relationship between the type of vascular access used at the initiation of dialysis and the survival prognosis revealed a significantly higher risk of death in patients undergoing dialysis with synthetic arterio-venous (AV) fistula, AV shunt, or catheter implantation into a central vein than in those receiving dialysis treatments with a native fistula. There was a significantly lower risk of death in the patient group in whom the vascular access was created at 3-6 months before initiation of dialysis than in those in whom such access was created at the time of initiation or within 3 months before the initiation of dialysis. An analysis of the risk factors affecting survival prognosis in maintenance hemodialysis patients showed that risk factors for death are post-dialysis systolic blood pressure over 180 mm Hg and lower than 120 mm Hg, blood pressure elevating progressively from the start to the end of dialysis, serum high density lipoprotein cholesterol concentration of less than 30 mg/dL, and a higher ultrafiltration rate. In comparisons of the death risk between the patient group with a history of intervention for ischemic heart disease and the patient group with a history of myocardial infarction or heart failure but without such intervention, among diabetes patients, those who underwent percutaneous transluminal coronary angioplasty had a significantly lower risk of death than those in whom no intervention was made.

Report on the annual statistical survey of the Japanese Society for Dialysis Therapy in 1996. Background Nearly 170,000 patients were treated by maintenance renal replacement therapy (RRT) in Japan in 1996. The current status of Japanese patients on RRT might, in some way, be suggestive for patients on RRT in other countries. Methods The Japanese Society for Dialysis Therapy conducts a questionnaire survey of virtually every dialysis facility in Japan at the end of each year. Here we present the results of our survey of patients undergoing RRT as of the end of 1996, as well as five-year trends (1992–1996) in some of the data. Results The response rate was 99.8%. At the end of 1996, there were 167,192 patients on maintenance RRT in Japan (1,328 persons per million population). The numbers of patients on maintenance RRT continued to increase during the five-year period. The gross mortality rate for that period ranged from 9.4% to 9.7%. Cuprammonium rayon was the most commonly used material (24.0%) for dialyzer membranes, followed by cellulose triacetate (18.7%). Approximately 5.0% of hemodialysis (HD) patients had a prior history of surgical release of carpal tunnel. The longer the years on HD therapy, the greater the proportion of patients with a history of such an operation. The predialysis plasma β2-microglobulin concentration was highest in patients aged 30 to 45years and declined slightly after the age of 45. There was no significant difference in the HbA1c level between continuous ambulatory peritoneal dialysis and HD patients, both in whom diabetes was the disease causing renal failure. Moreover, among HD patients with diabetes, there was a clear tendency for the HbA1c level to be higher when the normalized protein catabolic rate was higher. Conclusion This report summarizes the latest results of the survey on Japanese patients on RRT.

Although the etiology and pathogenesis of progressive renal failure is largely unknown, endotoxin is supposed to be one of the contributory factors. However, the distribution of endotoxin in liver cirrhosis has not been clarified. Therefore we studied the distribution of 3H-labeled endotoxin in the kidney in rats with CCl4-induced liver injury. Daily inhalations of CCl4 on rats for 6 and 10 weeks produced liver fibrosis (LF group, N = 5) and cirrhosis (LC group, N = 5), respectively. At 6 or 10 weeks, animals were sacrificed 24 hours after an intravenous injection of endotoxin labeled with 3H at the galactose moiety (12,000 cpm/1 g body weight). In the liver, 3H-labeled endotoxin was taken up mainly by Kupffer cells as determined by autoradiography. Compared to control rats, in rats of the LC or LF group the measured amount of 3H-labeled endotoxin per gram kidney or ml blood increased, while that of the liver was significantly decreased. A positive correlation of the amount of 3H-labeled endotoxin per weight or volume respectively was shown between kidney and blood, but not between lung or spleen and blood. These results suggest that overflow of endotoxin due to decreased inactivation in the liver causes endotoxemia in liver injury and that the resulting endotoxemia may directly affect the kidney. The resulting endotoxin-induced vasoconstriction may be a contributory factor for the progressive renal failure frequently observed in liver cirrhosis.

To clarify the effects of correction of anemia with recombinant human erythropoietin (r-HuEPO) on the hemostatic defects in uremia, hemostatic parameters were examined in 18 hemodialysis patients with renal anemia. Anemia improved significantly 12 weeks after r-HuEPO therapy (stage II) compared to pretreatment (stage I) and 6 weeks discontinuation (stage III) periods. Platelet count did not change among the three stages, however, mean platelet volume increased significantly at stage II in comparison with stage I. Ivy bleeding time (BT) significantly shortened at stage II and prolonged again at stage III. Although there were no significant changes in platelet aggregation, plasma TxB2, 6-keto-PGF1 alpha, F.VIII:C and F.VIII:Ag levels throughout the study, platelet adhesion and von Willebrand factor (vWf):Ag significantly increased at stages II and III. Augmentations in these parameters were more remarkable in BT-shortened patients (n = 12) than in the BT-unchanged group. These results indicate that correction of anemia with r-HuEPO brought about improvement in uremic hemostatic defect via the increase in red cell volume and vWf:Ag, and new production of platelets, reflected by the improvement in platelet adhesion.

It is commonly known that patients with a depressive disorder often have some medical comorbidity due to antidepressant medication, although tricyclic antidepressants are associated with cardiovascular disease [1]. They are often given to cardiac patients [1–3]. In particular, amitriptyline has been reported to account for approximately 39% of the deaths due to a tricyclic overdose [2]. Several studies have demonstrated that maprotiline, a tetracyclic antidepressant with noradrenaline reuptake inhibition, produces fewer cardiovascular effects than tricyclics [4]. Recent studies, however, have shown that the cardiac effects of maprotiline do not differ either in quality or quantity from those of the tricyclic substances. We report here on an elderly depressed patient on hemodialysis who had a cardiac arrest which may have been caused by maprotiline [1, 2].

A case of bilateral cortical necrosis (BCN) was reported because of her abnormal platelet count and aggregability. She was 26 years old primipara.In her past history, at the age of 11, she was operated because of papillary adenocarcinoma of the thyroid gland, when no abnormal bleeding was reported.After cesarean section, atonic hemorrhage occurred and anuria developed. Because BCN was suspected heparin and urokinase therapy were started (later, patchy BCN was verified by renal biopsy). Uremia was controlled by hemodialysis (3/week). Platelet count (Plt.) increased gradually to normal level within a week. After heparin cessation, Plt. continued to increase and exceeded 60×104/mm3. In spite of thrombocytosis, bleeding time (BT) was prolonged to more than 15 min. On 31st hospital day when Plt. was 40×104/mm3and BT more than 15 min., platelet aggregability was investigated by screen filtration pressure (SFP) method (normal range: 264.9±14.3mmHg when induced by 3μM ADP). Her aggregability was no more than 20mmHg. On 34th hospital day, she was attacked by generalized convulsion and tracheotomy was done. Despite 17 units of blood transfusion bleeding was not discontinued. Therfore, 6 units of packed platelet were transfused and bleeding was dramatically stopped within 2 hours. After this episode, BT was normalized while thrombocytosis persisted. On 59th hospital day when Plt. showed 48.1×104/mm3 and BT was 3.5min., platelet aggregability was investigated by SEP method and optical density (O. D.) method. Using SFP method 3μM ADP induced aggregability was 400mmHg. By O. D. method, 10μM ADP induced maximum aggregability (ADP max) was 32.8% (normal 70.2±2.6), 1μg/ml adrenaline induced maximum aggregability (adrenaline max) 90.8% (normal 40.6±4.0), and 1mg/ml collagen induded maximum aggregability (collagen max) 69.6% (normal 74.8±5.6), respectively.She discharged on 14th hospital day, when her creatinine clearance was 17L/day, BUN 31mg/dl, and creatinine 3.3mg/dl, and conservative management was indicated. On 178 th day after BCN, when Plt. revealed 27.6×104/mm3 and was 3min., platelet aggregability was investigated again. Using SFP method, 3μM ADP induced aggregability was 390mmHg, while by O. D. method, ADP max was 63.2%, adrenalin max 98.5%, and collagen max 82.4%, respectively.Throughout her clinical course, fibrin degradation products were 40μg/ml or less, fibrinogen 370-900mg/dl, and euglobulin lysis time 24 hours or more. CB-PC and cephalothin, which were administered when platelet aggregability decreased, were investigated in vitro by O. D. method, with no effect to platelet aggregability being found.

短時間作用性透析用抗凝固薬として最近臨床応用の試みられているタンパク分解酵素阻害薬の抗凝固作用を的確に反映する凝固時間測定法を明らかにする目的で, nafamostat mesilate (FUT-175: FUT), gabexate mesilate (GM), ヘパリンの抗凝固作用を各種の凝固時間測定法を用いin vitro, 臨床試験で検討した. in vitro試験では, 活性化部分トロンボプラスチン時間 (APTT), 全血APTT (WBAPTT), 血漿カルシウム再加時間 (PRT), 全血RT (WBRT) 全血凝固時間 (LWCT), セライト活性化CT (CCT), エラジン酸活性化CTはヘパリン, FUT使用時とも濃度依存性に延長するのに対し, カオリン活性化CT (KCT) はヘパリンでは延長するもののFUTでは高濃度に至るまで延長を認めなかった. KCTとLWCTの相関をみると, ヘパリン, FUTとも両者は有意に相関するものの回帰直線の傾きは各々0.08, 0.003と後者は前者に比し極めて小さく, KCTはFUTによる凝固時間の延長を的確に反映できないと考えられた. 一方, CCTとLWCTはFUT, ヘパリン, GM使用時とも有意に相関し, 回帰直線の傾きは各々0.46, 0.29, 0.63とCCTは各薬剤の抗凝固作用を鋭敏に反映することができた. FUTを用いた臨床試験時にもKCTはほとんど延長しないのに対し, 他の凝固時間測定法ではFUT注入部位直後の血液に著明な延長を認めた. GMを用いた透析時にもCCTは延長するのに対し, KCTの延長は極く軽度であった. カオリン, セライトとFUT, GMを混和し, FUT, GMの濃度を測定すると, カオリンでは濃度依存性にFUT, GM濃度が低下するのに対し, セライトでは変化は見られなかった. 以上の成績より, FUT, GMによる抗凝固作用をKCTは的確に反映し得ず, その機序としてカオリンによるこれら薬剤の吸着が推定された. 一方, CCTはFUT, GM, ヘパリンの抗凝固作用を的確に反映し, 測定の簡便性からも, 最も適した凝固時間測定法と考えられる.

透析適応の拡大, 症例の増加と透析管理期間の延長などに伴う現行透析液の問題点を改善する目的で, Na 140, K 2.0, Ca 3.3, Mg 1.0, Cl 109.3, acetate 37 mEq/l, 糖100mg/dlの組成から成る新しい透析液を処方し, 38例の安定期透析患者について, 従来のキンダリー液3号透析液と6ヵ月にわたるcross over studyを施行し, 臨床効果, 検査成績を比較検討した. 透析困難症の出現頻度は, 血圧低下, 気分不良, 筋硬直, 腹痛, 熱感などの項目で, 新処方液で有意に少なく, また困難症に対する処置回数も減少した.透析前のCa値は両群とも差はなかったが, 1透析当りのCa値の上昇は新処方液でわずかであり, 後値のイオン化Ca値も生理的範囲内に保たれ, かつPTHへの透析による抑制効果も認められた.Mg値は新処方液で透析前値の低下がみられ, 血糖については糖尿病性腎症による透析患者で, 透析中の変動が減少した.これらの成績から, 新処方液は従来の透析液に比して透析困難症や透析後の非生理的高Ca血症を抑制し, さらにMg濃度や糖尿病患者の透析中の血糖管理が容易であり, high flux typeの透析器や活性型ビタミンD剤が実用化された現状では, より有用な臨床効果を持つと考える.

急性肝炎の発症に伴い貧血の著明な改善を認めた慢性透析症例を経験したので, その臨床経過と貧血改善の機序について報告する.症例は36歳の女性, 昭和55年に慢性糸球体腎炎による慢性腎不全と診断され, 昭和57年5月血液透析導入, 以後週3回の外来血液透析を施行されていた. 透析導入前より高度貧血があり, タンパク同化ホルモンやタンパク透過性血液濾過器 (Duo-flux) を用いた濾過透析法 (HDF) などを試みたがいずれも著明な効果はみられず, Ht 15-18%程度の貧血がつづいていた.昭和58年11月の血液検査にてGOT 64, GPT 53KUとトランスアミナーゼ (Tr) の上昇がみられ, その後さらに上昇傾向を示したため, 精査・加療のため当科入院となった. 検査所見ではHBsAg(-), HBsAb(+), HA(IgM)Ab(-)であり, 他のウィルス抗体価の上昇もなく, 薬剤などの原因も考えにくく, さらに性器出血のため多量の輸血をした既往があることより輸血後のnonA, nonB hepatitisと診断した. Trは入院後も上昇したが, 発症後約4週をピーク (GOT 224, GPT 223KU) として低下傾向を示し, 8週後には正常化した. 一方, 貧血は肝炎発症とともに著明な改善を示し, 肝炎発症前のHt 16%からTr上昇のピークと一致してHt 30%まで上昇した. その後Trの正常化にやや遅れてHtは低下し, 肝炎発症後16週にはHt 21%まで低下した.本症例における貧血の改善は, 経過からみて今回の肝障害と因果関係を有することが推定される. 肝障害ピーク時の血清エリスロポエチン (Ep) および網状赤血球数は高値を示し, Tr正常化後のEpは測定感度以下であった. この結果から本症例における貧血改善の機序を考察すると, 肝障害によりhepatic erythropoietic factor (HEF) が産生され, これにより肝におけるEp産生が増加し, erythropoiesisが亢進したと考えられた. またHEF抑制に働くrenal inhibitory factorや骨髄抑制作用を持つuremic toxinsのprotein permeable HDFによる除去効果が寄与因子として作用した可能性も示唆された.

遺伝子工学によるヒトエリスロポエチン (rhEPO) は, 多くの臨床治験によって腎性貧血を確実に改善することが立証されつつある. しかしその一方で, ヘマトクリット (Ht) の上昇が透析効率の低下やダイアライザー残血の増加など, 透析技術上の問題点を起こすことが懸念されている. 本研究では貧血改善がこれら透析技術上の問題点に及ぼす影響を検討した.対象は安定期透析患者35例で, エリスロポエチン投与前2か月間とHtが10%以上上昇した時期の2か月間について, 透析効率, 残血の程度, ヘパリン使用量を比較検討した.透析による除去率はBUNでは有意の変化は認められなかったが, クレアチニン (Cr) と尿酸の除去率は有意に低下した. しかし, これらの透析前値には有意の変化は認められなかった. 透析前値が上昇すると除去量が増加するため, この程度の除去率の低下では透析前値に有意の変化をきたさないためと考えられる. 血清K濃度の透析前値にも有意の変化はみられなかったが, 透析前K濃度が6mEq/l以上に上昇した例が35例中7例にみられ, うち5例ではカリメートの投与を必要とした. ダイアライザー内残血についても有意の増加は認められなかったが, 残血指数1度以上の増加を示した例が8例 (23%) あり, うち6例ではヘパリンの増量を要した.以上の成績より, エリスロポエチン投与による貧血の改善が, 透析効率の低下と残血の増加をきたす傾向のあることは否定できない. いずれも既存の透析技術で対応可能の範囲の変化であるが, 症例によっては高度になる可能性があり, 血清K濃度やヘパリン使用量に十分注意する必要がある.

The southwestern region of Japan is known as a very high endemic area of human T-cell lymphotropic virus type 1 (HTLV-1), the etiologic agent for adult T-cell leukemia (ATL) and probable causative agent for tropical spastic paraparesis and its Japanese version, HTLV-1-associated myelopathy (HAM). Hemodialysis (HD) patients seem to be at high risk for HTLV-1 infection even in other regions of Japan because they sometimes receive multiple blood transfusions. We examined antibody against ATL-associated antigen (ATLA-Ab) in 1,132 HD patients, including 1,066 patients in nonendemic areas (Chubu and Tokyo) and 66 in a highly endemic area (Okinawa). The HD patients in Okinawa showed the highest prevalence, 21.2% (14/66), while those in the Chubu area showed the lowest, 1.1% (10/846), and those in the Tokyo area an intermediate value, 2.7% (6/220). The prevalence of HD patients in each area was significantly higher than that of local blood donors, reflecting an increased prevalence roughly corresponding to the respective endemic rate. The average prevalence of ATLA-Ab among the HD patients was 2.7% (30/1,132), which was similar to that of HBs antigen (3.2%). In the nonendemic areas, 15 of 16 patients with ATLA-Ab had a history of blood transfusions, showing a significant correlation to the presence of ATLA-Ab (P less than 0.01), although four had family histories related to the endemic area. The relative risk of the presence of ATLA-Ab for HD patients with a history of blood transfusions was calculated as 10.3. In the endemic area of Okinawa, the relationship to blood transfusion was not so close, probably masked by the high background prevalence.

透析液の有効利用を図るために, 小容量の透析液バッチ槽を用い, これを一定時間毎に切り替える連続的バッチ透析法を考案した. 本方法による透析液節減効果について, one pool modelに基づくシミュレーション解析を行ったところ, 除去対象物質について臨床データ (体液量, 体内産生速度, 初期濃度), 透析条件 (全透析時間, 透析器ダイアリザンス) および除去必要量を設定することにより, 透析液必要量を最小にする最適バッチ透析条件 (バッチ槽体積, 切り替え時間およびこれに対応する切り替え回数) を求めることができた. 尿素を対象物質とすると, バッチ槽体積の増加とともに最適切り替え時間は増加したが, 透析液の使用量は, 除去必要量が少ない (25g以下) 場合に若干の低下傾向がみられるのを除き, 除去必要量にかかわらずほぼ一定であった. この成績から, 本法では通常のシングル・パス透析法と比較した場合透析液使用量が約50%低減し, 透析液利用効率の向上が示された. これらの検討結果に基づいて, 連続的バッチ透析装置の設計, 試作を行い, in vitro実験を行ったところ, シミュレーション解析の予測と良い対応を示した. 以上の成績より連続的バッチ透析法は, 血液透析における透析液必要量を節減し, そのコスト・パーフォーマンスの向上に有用であると考えられた.

Why has the gross mortality of dialysis patients increased in Japan? Background The gross mortality of Japanese chronic dialysis patients gradually increased from 8.1% in 1983 to 9.4% in 1997. We describe the demographic changes in dialysis patients and clarify why the gross mortality has increased. Methods Data used in our analysis were taken from annual reports by the Patient Registration Committee of the Japanese Society for Dialysis Therapy. The relative risk of death was calculated by a logistic regression procedure and Cox proportional hazard model. Results The first-year survival starting from the initiation of dialysis therapy slowly improved from 0.836 in 1983 to 0.857 in 1996, but 5-year and 10-year survival consistently decreased in the same patient groups. The patients' mean age of beginning dialysis steadily increased from 51.9 in 1983 to 62.2 in 1997. The incidence of patients with diabetes as the original disease showed a tremendous increase from 15.6% in 1983 to 33.9% in 1997, and patients with nephrosclerosis also showed a twofold increase in our population. Heart failure accounted for 30–35% of mortality until 1991, but this started to decrease after 1992, when recombinant human erythropoietin became clinically available, and the level fell to 23.9% by 1997. The relative risk of death in the first year of initiating dialysis therapy decreased to almost half of the reference year 1983 ( P Conclusion The increase in the gross mortality of Japanese dialysis patients might not be due to a deteriorating quality of dialysis therapy, but rather is a reflection of accepting patients with older age and comorbid factors contributing to higher risks of mortality with dialysis therapy.

Several lines of evidence suggest that beta 2-microglobulin (beta 2M) accumulation in long-term hemodialysis (HD) patients results in so-called dialysis-associated amyloidosis (DAA), which is clinically manifested by carpal tunnel syndrome, osteoarthropathy, and the other organ involvements. For the purpose of preventing the beta 2M accumulation, the efficiency of beta 2M removal during (HPM), hemofiltration (HF), HD, and charcoal hemodiafiltration (HDF) with high-performance membranes (HPM), hemofiltration (HF), HD, and charcoal hemoperfusion was evaluated. Among 27 patients treated with these methods, significant beta 2M removal was noted in HDF with HPM and HD with polyacrylonitril (PAN) membrane. However, treatment of HDF with HPM for more than 6 months caused no remarkable improvement in clinical symptoms of patients, and serum beta 2M levels decreased in only two out of 15 patients. These results imply that beta 2M might be most effectively removed by HDF with HPM and HD with PAN membrane, but further long-term studies will be necessary to conclude whether these procedures could become successful therapeutic regimen for DAA.