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糖尿病性腎症は末期腎不全の原因としてもっとも頻度が高く, 合併症が多く予後不良で, 多くの医療資源を要する. 糖尿病性腎症による透析導入患者数の今後の動向により, 透析医療が大きな影響を与える可能性がある. そこで, 国民人口動態調査と日本透析医学会統計調査委員会調査をもとに予測を試みた.1995年から2004年のわが国の糖尿病性腎症を原疾患とする慢性透析新規患者の性年齢別新規患者数と, わが国の性年齢別人口とその推測値から, 2005年から2015年の糖尿病性腎症による新規慢性透析患者数を推計した. 糖尿病性腎症による慢性透析患者推計値は, 2010年では男12,579, 女5,756, 計18,335名, 2015年では男14,813, 女6,575, 計21,388名と2004年に比べ総計はそれぞれ30.6%増, 52.2%増と推計された. 50-54歳, 55-59歳では2004年までの増加傾向が消失ほぼ平坦に, 60-64歳では2010年から増加傾向が減少傾向に変化した. これらの世代の導入率には大きな変化がないので, これは年齢別人口の変化によるものであった. 65歳～の世代では, 各年齢とも増加傾向を示し, もっとも導入数が多い年齢は従来の65-69歳から70-74歳に移行することが確認された.医療統計による推計には, 将来の医学の進歩, 健康保険制度の変化など, 予測不能などの危うさがある. この欠点を認めた上で, 本研究は, 今後の透析医療が立ち向かうべき対象として, 糖尿病性腎症による慢性透析患者の増加, しかも高齢導入患者の増加があることを明らかにした.

今回われわれは, 深部出血を繰り返す重症血友病Bにステロイド抵抗性ネフローゼ症候群を合併した症例に対して, 体外限外濾過 (ECUM) を施行することにより浮腫のコントロールを可能にした. また, インヒビター治療剤である乾燥血液凝固因子迂回活性複合体 (APCC製剤: FEIBATM) を使用することにより, 体外循環療法時の止血管理を可能にしたので報告する. 症例は31歳男性. 1歳時に関節内出血を起こし, 第IX因子活性が1.0%未満であったことから, 血友病Bと診断された. 13歳時に第IX因子インヒビターを有するようになり, 乾燥ヒト血液凝固第IX因子複合体 (PCC製剤: PROPREX STTM) によるバイパス療法を行っていたが, 頻回に関節内出血を繰り返していた. 2003年8月より全身の浮腫, 嘔気が出現し, 低蛋白血症, 蛋白尿を認めたため, ネフローゼ症候群の診断で入院となった. ネフローゼ症候群に対しループ利尿剤, アンジオテンシンII受容体拮抗薬とプレドニゾロンの投与を開始したが, 治療抵抗性であった. 全身浮腫の悪化と, 消化管浮腫に伴う嘔吐のため全身状態が悪化した. そのため, 体液量の管理を目的に, ECUMを施行した. ネフローゼ症候群は寛解しなかったが, 全身浮腫は消失した. また, 関節内出血は改善せず, 進行性の貧血を認めた. そのため, PCC製剤からAPCC製剤によるバイパス療法に変更したところ, 関節内出血はコントロール可能となり, 有意な止血効果が認められた. また, APCC製剤を使用することにより内シャント造設術の際には, 出血による合併症を回避することができた. また, 抗凝固剤nafamostat mesilateを使用し, 体外循環療法も可能であった. このような症例はこれまで報告がなく, 今後血友病B患者のネフローゼ治療や体外循環療法を選択する上での指標として極めて貴重であると考える.

Acetate-free biofiltration (AFB) is a special hemodiafiltration (HDF) modality performed with a base-free dialysate and simultaneous injection of non-pyrogenic sodium bicarbonate solution. The purpose of this study was to investigate the difference of cytokine production by conventional bicarbonate hemodialysis (BCD), standard HDF and AFB in the same patients. Eight stable hemodialysis patients were treated in random order with BCD, HDF and AFB every 4 weeks. The production of interleukin-1 beta (IL-1 beta) and interleukin-1 receptor antagonist (IL-1Ra) by peripheral blood mononuclear cells (PBMC) was investigated without stimulation and with stimulation by a small amount of endotoxin (ET)-contaminated beta 2-microglobulin (beta 2M) and lipopolysaccharide (LPS) before and after dialysis treatment in the last sessions during all periods. To serve as controls, 14 healthy volunteers participated in this study. In spontaneous IL-1Ra production, the values of before and after AFB were not significantly different from that of the controls, and the values of before and after BCD and before HDF were significantly higher than that of the controls. In LPS-stimulated PBMC, IL-1 beta production before and after AFB was not significantly different from that of the controls, and before and after BCD and HDF was significantly higher than that of the controls. In ET-contaminated beta 2M-stimulated PBMC, IL-1 beta production before and after AFB was not significantly different compared to the controls, and the production was significantly lower than that before and after BCD and HDF. In addition, IL-1Ra production after AFB was not significantly different from the controls, and the production was significantly lower than that before and after BCD and HDF. It was concluded that a lower cytokine production by AFB may have the effect of preventing dialysis-related complications.

End-stage renal failure due to tuberous sclerosis is rare and there is no previous report of a patient with tuberous sclerosis undergoing long-term hemodialysis for over 18 years. The patency rate for a dialysis prosthetic graft is low, however, our patient's graft survived over 16 years. For thrombotic occlusion of a graft, we performed percutaneous thrombectomy and balloon angioplasty and salvaged graft occlusion. Moreover, this case is the first report in which the interventional procedure (mechanical thrombectomy and balloon angioplasty) could be observed by intravascular ultrasound in addition to angiography.

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.

BACKGROUND There has been recent interest in the importance of visceral fat (VF) for the development of atherosclerosis. The purpose of this study was to examine associations between VF and multiple risk factors as well as the prevalence of carotid atherosclerosis in chronic haemodialysis patients. METHODS We classified 77 non-diabetic haemodialysis patients into 'low VF', 'middle VF' and 'high VF' groups after determining VF area using computed tomography. Systemic atherosclerosis was assessed from intima-media thickness (IMT), plaque score (PS) and stiffness parameter beta (stiffness-beta) measured by high-resolution B-mode ultrasonography. RESULTS Compared with the low VF group, the high VF group exhibited (i) significantly higher fasting plasma insulin (11.0 +/- 6.8 vs 7.1 +/- 2.9 micro U/ml, P = 0.0061); (ii) significantly higher plasma triglycerides (141.8 +/- 94.0 vs 86.5 +/- 32.5 mg/dl, P = 0.0032); and (iii) significantly lower plasma high-density lipoprotein cholesterol (42.1 +/- 14.5 vs 53.0 +/- 15.7mg/dl, P = 0.0134). Moreover, the high VF group had a higher prevalence and extent of carotid atherosclerosis: IMT was 0.69 +/- 0.13 vs 0.61 +/- 0.12 mm (P = 0.0239), PS was 4.8 +/- 3.2 vs 2.4 +/- 3.6 (P = 0.0236) and stiffness-beta was 11.4 +/- 3.1 vs 8.5 +/- 3.0 (P = 0.0082) in the high and low VF groups, respectively. CONCLUSION We show that VF is associated with the prevalence of carotid atherosclerosis as well as with hyperinsulinaemia and lipid abnormalities in chronic haemodialysis patients.

本邦では, 透析患者の終末期において, 血液透析 (HD) が安定して施行できている患者の自己決定を尊重し, HDを中止することについての生命倫理学的研究は殆どない. 今回, われわれは, 透析医 (552名) を対象として, 安定したHDを受けている悪性腫瘍終末期症例を提示し, いくつかのシナリオに対して, HDを中止するか, 継続するかの意識調査と, advance directives (AD), 尊厳死, 尊厳生についてどのように考えているかの意識調査を全国的規模で行った.434名 (78.6%) から回答が得られたが, 有効回答は427名 (77.4%) であった. ADおよび尊厳死が法的に認められていない現状において, ADの有無で比較すると, (1) 家族がHD中止を申し出た場合, (2) 家族がHD継続を申し出た場合とも, ADがあるとHDを中止する回答は有意に増加した ((1) 48.0%→78.9%, (2) 0.2%→2.6%). さらに延命療法を中止しても法的責任は問われないと仮定すると, ADがあるとさらにHDを中止する回答は増加した ((1) 90.9%, (2) 11.9%). ADと尊厳死を必要であると回答した透析医はそれぞれ74.0%, 83.1%であったが, 法制化も必要と回答した透析医は56.4%, 63.7%に減少した. 尊厳死と尊厳生の比較では, 尊厳生を支持する透析医は, 尊厳死を支持する透析医よりも多かった (47.1%, 15.9%).今回の結果は, 現状でも, 透析医および家族が患者の自己決定を尊重すると, ADによる尊厳死が行われる可能性があることを示唆し, 多くの透析医がADや尊厳死を必要と考えている. 一方, 尊厳生は人間にとって非常に大切なことであり, 尊厳死よりもこの言葉を支持する透析医が多かったと考える. すべての国民は個人として生きる権利を認められており, 本邦では, 終末期にも自分が考える尊厳ある生き方を貫くということから始め, 家族および社会が納得する範囲で, 先ず尊厳生によるADが自己決定のために重要であると認識させる努力をすべきである.

Background. Recently, careful attention has been paid to multiple risk factor syndromes, such as syndrome X, insulin-resistance syndrome, and visceral-fat syndrome, in terms of the development of coronary artery disease, which is also the major cause of death in hemodialysis patients. The purpose of this study was to evaluate the impact of visceral fat accumulation on these multiple risk factors in hemodialysis patients. Methods. Seventy-two stable outpatients (35 men, 37 women) participated in this study. After determination of the visceral fat area and the subcutaneous fat area by a computed tomography scanning technique, they were classified into two groups according to the value of the visceral fat area. Fasting blood samples were drawn for lipid and carbohydrate data. Results. The high-visceral fat group exhibited a significantly (1) higher insulin resistance index, (2) higher level of triglyceride, (3) lower level of high-density lipoprotein cholesterol, and (4) a higher atherogenic index, in comparison with the low-visceral fat group. Moreover, they had (5) a higher frequency of a history of coronary artery disease (33.3% vs 8.3%; P < 0.01). These findings are completely in accordance with the visceral fat syndrome. Conclusions. Visceral fat accumulation in hemodialysis patients has effects on lipid and carbohydrate metabolism, and it may increase the risk of coronary artery disease.

当院では残存腎機能が比較的維持されている腹膜透析 (PD) 患者において, 1週間に1日以上の休息日を設けたPD処方を行っている. 今回, PD休息日が患者のQOLにどのように影響しているのか, また, 今後の看護支援のあり方について検討した.対象および方法: 外来通院している腹膜透析患者のうち, 1週間に1日の休息日を実施している7名を対象とし, 受け持ち看護師の患者資料をもとに個々の患者と面接を行い, 休息日についてのアンケート調査を実施した. また, 過去に休息日を有するPDを行っていた5名にもアンケート調査を実施した.結果: 休息日により6名は行動範囲が拡大され交遊時間も延長し, この中で5名が大きな精神的なゆとりを得ることができた. また, 休息日に貯留液がないために違和感を感じている患者, 休息日は治療日よりも食事や水分制限に注意が必要になってくることに不安を感じている患者, 休息日に透析不足や溢水などが起こるのではないかという不安を感じている患者がそれぞれ4名いたが, 全例休息日のある透析処方に満足していると回答した. 過去に休息日を有するPDを行っていた症例の検討では, 毎日PDを行うことにより, 全例, 行動範囲が縮小し, 交遊時間が短縮し, ストレスが増加したと回答した.結論: PD休息日により, 目的に合わせたQOLの向上が得られていることが, 明らかになった. 今後, この治療を患者の不安なく行うためには, 援助者自身のカウンセリング技術や指導内容をさらに充実させる必要がある.

ブラッドアクセスカテーテルを鼠径部に留置する場合, 当院では, コアクシャル型UKカテーテルを使用する際には, 歩行が可能であったという報告に基づき歩行を許可しているが, ダブルアクシャル型カテーテルを使用する際には, 同様の報告がないため歩行禁止としている. 今回, 各種ダブルアクシャル型カテーテルの柔軟性に対する基礎的研究を施行し, その中で最も柔軟性のあるカテーテルを使用し, 鼠径部に留置した時の体動を中心とした臨床的研究を行った.基礎的研究: コアクシャル型ブラッドアクセスUKカテーテル (UK-C), ダブルアクシャル型ブラッドアクセスUKカテーテル (UK-D), ダブルアクシャル型Vas-cath Flexxicon, ダブルアクシャル型Quinton血管留置用カテーテルを用いて, カテーテルの硬度を常温と37℃の条件で測定した. 常温ではUK-Cが最も硬度が低かったが, 37℃の温水ではUK-Dが最も硬度が低下した.臨床的研究: ブラッドアクセスとして, 最も柔軟性のあるUK-Dを使用し, 観察期間は6回のHD施行後までとした. 内頸静脈からアプローチした症例 (IJV group, n=20) の体動は制限しなかったが, 大腿静脈からアプローチした症例 (FV group, n=20) には体動を制限した. 試験開始時と終了時の体温, 白血球数, CRP, 血流量は両groupとも試験開始時と終了時で有意差はなかった. 試験終了時のカテーテル挿入部と縫合部の発赤発生率は, 両groupで有意差はなかった.UK-Dを鼠径部に短期間留置した場合, 本研究で許可した体動では内頸静脈からのアプローチと比較し, 臨床上問題となる感染や血栓形成には明らかな差は認めなかった. よって, 柔軟性のあるUK-Dを使用した場合には, 短時間の歩行や座位などの体動は許容範囲内であると思われた.

It has been reported that uremia is a state of oxidative stress and may play an important role as a pathological cause of various uremic complications. Oxidative stress is known to increase conversion of deoxyguanosine to 8-hydroxy-2-deoxyguanosine (8-OHdG) in DNA, and 8-OHdG is used as a marker of oxidative DNA damage. We evaluated plasma and urinary concentrations of 8-OHdG in 49 patients (male 28, female 21; mean age 65 years; diabetic 27, nondiabetic 22) with chronic renal disease (CRD) and 22 patients (male 14, female 8; mean age 63 year; diabetic 7, nondiabetic 15) on maintenance hemodialysis (M-HD). Plasma concentrations of 8-OHdG were measured using a highly sensitive ELISA kit, and the urinary mean concentrations of 8-OHdG were measured using an ELISA kit. Plasma concentrations of creatinine (Cr), Urea nitrogen (UN), and β2-microgloblin (β2-MG) and 24-h creatinine clearance (CCr) were also measured in CRD patients. Furthermore, 8-OHdG was measured before the dialysis session in M-HD patients. The plasma concentration of 8-OHdG in patients on CRD was significantly correlated with serum-creatinine (S−Cr), serum-umea nitrogen (S-UN), and β-MG (P 50 ml/min,n=12), 0.108±0.41 ng/ml; CRD (CCr

Keywords: arteriovenous fistulae; haemodialysis Background. Complications of haemodialysis vascular patients; intravascular ultrasound imaging; percutanaccess have emerged as a major cause of patient eous transluminal angioplasty morbidity. Intravascular ultrasound imaging is a new technical modality providing visualization of the vessel lumen and wall structure in a cross-sectional fashion. Percutaneous transluminal angioplasty has long been used in the treatment of stenoses of arteriovenous Introduction fistulae. However, there is no detailed quantitative information on the stenotic lesion and the morpholo- The rapid growth of end-stage renal failure progical change by angioplasty. grammes worldwide has been accompanied by a Methods. Intravascular ultrasound studies were per- tremendous increase in vascular access-associated morformed in 40 haemodialysis patients with 63 stenoses bidity in haemodialysis patients. Satisfactory vascular in arteriovenous fistulae who had percutaneous translu- access is the most critical factor in assuring the wellbeminal angioplasty. The patients were qualitatively and ing of haemodialysis patients. Adequate blood flow in quantitatively evaluated for echogenic patterns and the arteriovenous fistule (AVF ) may have an influence morphological changes before and after angioplasty. that is vital to the outcome of the dialysis patient. Results. Morphological plaque features in stenotic Percutaneous transluminal angioplasty (PTA) has been lesions were classified as 37 soft (58%), five hard (8%), used in the treatment of stenosis in AVF and accepted 20 mixed (32%), and one calcified sites. Plaque frac- as an alternative to surgical revision, it is still the most tures after angioplasty were detected in 45/63 (71%) common intervention [1–5]. Angiography has been the instances. The lumen cross-sectional area was found standard method to evaluate the extent of vessel disto be dilated approximately threefold (from 3.8±2.4 ease. However, angiography provides an image of to 11.1±4.5 mm2) and the external elastic membrane lumen contour, but does not yield information about cross-sectional area was dilated approximately twofold the lumen characteristics and vessel-wall structure. (from 11.1±5.3 to 19.8±8.1 mm2) after angioplasty. Intravascular ultrasound (IVUS ) imaging is a new Conclusion. These results indicate that intravascular modality that provides visualization of the vessel lumen ultrasound allows both qualitative and quantitative and wall structures in cross-section. IVUS imaging assessments of arteriovenous fistulae in haemodialysis provided valuable information on the degree of stenosis patients. The results further suggest that the mechan- and the type and extent of atherosclerotic plaques. ism of expansion of arteriovenous fistulae stenoses Several in vitro studies have demonstrated excellent by percutaneous transluminal angioplasty involves correlation between ultrasound images and the findings stretching of the vessel wall as well as plaque fractures. of histological investigation [6–12].

CAPD施行中の慢性腎不全患者に対するAztreonam (AZT) の薬物動態を動脈内投与と腹腔内投与の両面より検討し, その臨床応用も併せて検討した. 1) CAPD施行中の6例を対象とし, 非腹膜炎時にAZTを1g静注 (I群, n=3), および腹腔内1g投与 (II群, n=3) に分類し, 経時的に採血し血漿中AZT濃度をHPLC法により測定し, I群は2コンパートメントモデル, II群は3コンパートメントモデルを用い各種薬物動態学的パラメータを求めた. また, 2) 腹膜炎を併発した患者6名に対し, AZTを腹膜内反復投与を行い血漿中AZT濃度を経時的にモニターした. I群のT1/2は平均7.40±2.57hrと延長が認められ, 投与量もしくは投与間隔の調節が必要であると考えられた. II群においてはTmax 4.28±0.72hrであり, 比較的速やかに血中に移行することが示された. 腹膜炎時の反復投与では6症例のうち尿量0の1症例のみが, 120時間後においてAZT濃度の高値を示したが, 他の5症例では, 蓄積性は認められなかった. CAPDにおけるAZTの薬物動態は残存腎機能の影響を受けることが示唆され, 投与量補正の際には残存腎機能に対する配慮が望まれる.

CAPD歴約6か月の51歳, 男性が, 突然, 除水量低下と体重増加が出現し, 胸部X線検査で右側胸水貯留が認められたため, 精査加療目的で入院となった. 末梢の浮腫および炎症所見は認められず, 胸水中糖濃度が血糖より高かったため, 腹膜灌流液の胸腔への移行を疑い, 99mTc-MAAを用いて確定診断を施行した, 本症の治療として, 胸水排出後に自家血の胸腔内注入による胸膜癒着術を試みたところ, 単独では無効であったが, CAPDの短期間中断およびその後に1回注液量を減少させたCAPDを併用することによって効果が得られた. 本療法は, 副作用なしに施行できたが, 永久的な胸膜の癒着が得られるかどうかは不明であり, 今後長期的に経過を観察する必要がある.

Plasma exchange has been employed in many fields. We reviewed its effect in 5 cases of refractory hyperbilirubinemia after acute liver dysfunction excluding fulminant hepatitis. Three liters of plasma replacement per session of plasma exchange was sufficient to remove bilirubin from the plasma effectively, but plasma exchange over a period of 3 consecutive days was needed to remove bilirubin from the whole body. In cases of a serum total bilirubin concentration of above 30mg/dl, the effect was less and far more plasma exchange was required. Posttransfusional hepatitis occurred in a few cases. Although plasma exchange certainly represents the most effective method for reducing the bilirubin levels, further studies on the effects of plasmaperfusion are needed since with this procedure post-transfusional hepatitis never occurs.

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.

Patients receiving hemodialysis are generally considered to be at increased risk of developing tuberculosis. In the current study, in order to evaluate the usefulness of serological tests in dialysis patients, serum antibodies for tuberculous glycolipids antigen (TBGL) and for lipoarabinomannan (LAM) were measured in hemodialysis patients. The present study included 243 hemodialysis patients. Serum antibodies for TBGL and LAM were measured. Tuberculin skin tests were carried out and chest X-rays evaluated at the same time. There were no patients with active tuberculosis at the time of blood sampling. Thirty-six patients (14.8%) and 25 patients (10.3%) were positive for anti-TBGL antibody and anti-LAM antibody, respectively. One hundred and fifty-five patients (63.8%) were positive for tuberculin skin testing and 123 patients (50.6%) had old pulmonary tuberculosis on their chest X-ray. There was no significant correlation between the results of anti-TBGL antibody and anti-LAM antibody. There were no relationships among the results of tuberculin skin test and the two serological tests. However, positivity of anti-TBGL antibody and anti-LAM antibody was significantly higher in patients with findings of old tuberculosis on the chest X-ray than those without findings. The current results show that these serological tests are positive more frequently in hemodialysis patients without any proof of active tuberculosis than in healthy subjects (2%) and careful interpretation is necessary for relevant results.

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.

The aim of this study was to evaluate the contrast enhancement, pharmacokinetics, dialyzability, and safety of gadodiamide in patients on hemodialysis.Thirteen hemodialysis patients with abdominal disease were examined after receiving intravenous gadodiamide (0.1 mmol/kg body weight) by magnetic resonance imaging (MRI) and were dialyzed at l, 3, 5, and 8 days. Blood samples were obtained immediately before, during, and at the end of the first hemodialysis session and immediately before and at the end of the next three sessions. The complete blood count, blood biochemistry, beta2-microglobulin, and gadolinium were measured. Dialysis of urea, creatinine, and gadolinium during the first hemodialysis session was assessed. Precontrast and postcontrast MRI and Gd-enhanced MR angiography (MRA) images were reviewed and visually evaluated by two radiologists; their evaluation was based on consensus.Gadodiamide did not cause any changes in renal function. An average of 73.8%, 92.4%, and 98.9% of the gadodiamide dose was eliminated by the end of the first, second, and third hemodialysis sessions, respectively. The average half-time of gadodiamide was 1.93 h (SD 0.55). The mean clearance of gadodiamide during hemodialysis was 63.5 ml/min (SD 21.9). There were no side effects related to the injection of gadodiamide. In all cases, diagnosable MRI and MRA images were obtained after gadodiamide injection in the hemodialysis patients.In hemodialysis patients, gadodiamide achieves diagnosable images. It is dialyzable and can be used safely without measures to increase excretion.

The incidence of chronic kidney disease and its progression to end-stage renal disease (ESRD) differs between genders, so it can be surmised that the incidence of ESRD is different between men and women. We analyzed the annual incidence of ESRD by gender for a 20 year period, from 1983 to 2002, using Japanese Society for Dialysis Therapy (JSDT) registration data. The annual incidence of ESRD was calculated as the number of incident dialysis patients divided by the census population of the previous year in each gender, and expressed per million of each population (male and female). In men, the incidence of ESRD increased from 99.9 in 1983 to 330.2 in 2002, whereas it was 66.6 in 1983 and 184.9 in 2002 in women. The difference of incidence of ESRD from men to women increased from 33.3 in 1983 to 145.3 in 2002. The mean age at the start of dialysis was 51.5 years (men) and 52.5 years (women) in 1983, it increased to 63.8 years (men) and 66.1 years (women) in 2002. The difference in mean age increased from 0.9 years in 1983 to 2.3 years in 2002. There was no clear relationship between the available dialysis station per 100 000 population and the men to women ratio in the prevalent dialysis patients among the 47 prefectures. The acceptance of dialysis therapy might not be strong enough to explain the increasing difference in ESRD incidence between men and women in Japan. Differences in the socioeconomic conditions and lifestyles between men and women, which might be related to the gender difference in incidence in ESRD, should be studied further.

A 44 year-old woman was diagnosed as having chronic renal failure due to rapidly progressive glomerulonephritis (RPGN) from one year earlier. She has been managed with steroid therapy and hemodialysis. The patient was admitted to our hospital because of fever and sudden disturbance of consciousness with generalized convulsion on October 30, 2003. She showed mild meningeal irritation. Cerebrospinal fluid (CSF) examination demonstrated a cell count of 60/microl, protein level of 70 mg/dl, glucose level of 52 mg/dl, and chloride (Cl) level of 116 mEq/l. Both the CSF culture for Mycobacterium (M.) tuberculosis and the conventional single polymerase chain reaction (PCR) for M. tuberculosis DNA in CSF were negative results on admission. In contrast, nested PCR of preserved CSF samples obtained at admission demonstrated positive results. We diagnosed her conditions as tuberculous meningitis (TBM) and administered a total of 3 anti-tuberculosis agents over a period of about 2 months. Her clinical condition and CSF examinations improved immediately in response to anti-tuberculosis treatment. Serial CSF cultures for M. tuberculosis and the serial single PCRs for M. tuberculosis DNA in CSF were all negative during the course of anti-tuberculosis treatment. However, serial nested PCR results gradually converted from positive to negative, correlating with the improvement in clinical conditions during the course of anti-tuberculosis treatment. Therefore, nested PCRs were much more useful for the rapid and accurate diagnosis of TBM and for assessment of the clinical course and anti-tuberculosis treatment response of TBM than conventional CSF cultures and single PCRs. To the best of our knowledge, there have been few previous reports of diachronic study in which the serial nested PCR was used to test CSF samples obtained earlier in the clinical course of TBM. In conclusion, our findings suggest that nested PCR for M. tuberculosis DNA in CSF was highly useful not only for rapid and accurate diagnosis of TBM, but also for assessment of the antituberculous treatment response in cases highly suspected of TBM despite negative results on conventional cultures and single PCRs.

Background. Trends in age-adjusted or age-specific incidence rates of end-stage renal disease (ESRD) have never been examined in Japan, a major ESRD epidemic area. Methods. A nationwide registry has provided the number of ESRD patients commencing maintenance renal replacement therapy for time period from 1983 to 2000. We computed gender- and age-specific incidence rates of ESRD over 2-year periods, in total or by cause. Age-adjusted incidence rates were calculated using the 1985 Model Population of Japan as the standard. Results. Causes of ESRD in 1999–2000 were, in order of decreasing frequency, diabetic nephropathy, chronic glomerulonephritis, unknown causes, nephrosclerosis and polycystic kidney disease in men, and chronic glomerulonephritis, diabetic nephropathy, unknown causes, nephrosclerosis and polycystic kidney disease in women. The age-adjusted all-cause incidence of ESRD increased until 1995–1996, but has since levelled off in both genders. The age-adjusted rate for diabetic nephropathy has been rapidly increasing, while that for chronic glomerulonephritis has decreased since 1995–1996. The former rate exceeded the latter in 1997–1998 in men. All-cause ESRD has rapidly increased in the eighties age group, whereas the increase slowed down in younger age groups in the late 1990s. The rate for diabetic nephropathy has linearly risen in almost every age group in men, whereas it began to level off in women aged 40–59 years at about 1995. For chronic glomerulonephritis, the rate had already started to decline in the mid-1980s in those aged

Japan has the highest prevalence of dialysis patients in the world. According to the Annual Report of the Japanese Society for Dialysis Therapy (JSDT; 2002), the total dialysis population was 229 538 (1801.5 patients per million population) at the end of 2002. The annual crude mortality rate has been less than 10%. Survival rates in the incident dialysis patients were 0.874 for 1 year, 0.609 for 5 years, and 0.391 for 10 years. Despite the increased acceptance for dialysis of elderly patients, those with comorbid conditions, and those with diabetes mellitus, the adjusted hazard ratios for death have been improving since 1983. This improvement was obtained by delivering a dialysis dose of Kt/V 1.33 and dialysis sessions of 4 h. Independently of the JSDT registry, there exists a local dialysis registry in Okinawa, the Okinawa Dialysis Study (OKIDS) registry, in which are filed the records of every chronic dialysis patient from the beginning of dialysis therapy in 1971 to the end of 2000. Several outcome studies have been conducted to determine the factors related to survival, using the data in that registry. There are distinct differences in environmental and socioeconomic conditions and lifestyles within a given country, and between countries and ethnic groups, that may affect the survival of dialysis patients. In this article, both the JSDT registry and OKIDS data are reviewed in order to identify factors related to the survival of chronic dialysis 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.

Background: During hemodialysis session, several adverse reactions can occur on platelets, which are attributable to bioincompatibility of the dialysis membrane. Glycoprotein IIb/IIIa (GPIIb/IIIa) is the receptor for fibrinogen, which mediates platelet aggregation and adhesion. Accordingly, we compared the influence of a cellulose triacetate (CTA) and polysulfone (PS) membrane on GPIIb/IIIa and platelet activation. Methods: Blood samples from 5 patients on hemodialysis were taken at 0 time, 15 min, 30 min, 60 min and 240 min, during a single hemodialysis session, by a crossover design using CTA or PS. Platelet count and plasma concentration of GPIIb/IIIa, β-thromboglobulin (β-TG) and platelet factor 4 (PF-4) were measured. GPIIb/IIIa was measured by flow cytometry. β-TG and PF-4 were measured by ELISA. Results: There was no significant change in the total amount of GPIIb/IIIa during dialysis session between the CTA and PS. However, the level of bound GPIIb/IIIa was significantly (p < 0.0002) increased from 1,426 ± 435 to 40,446 ± 2,777 mol/PLT with PS. In contrast, there was no significant change with CTA (3,258 ± 1,469 to 4,301 ± 1,422 mol/PLT). The platelet counts and β-TG and PF-4 behavior during the dialysis session did not show significant change between the PS and CTA. Conclusion: The characterization of changes in platelet membrane receptor (GPIIb/IIIa) may be a useful marker for studying the biocompatibility of dialysis membranes. On platelet aggregation, CTA might be more biocompatible membrane than PS.

Sclerosing encapsulating peritonitis (SEP) is characterized by the diffuse appearance of marked sclerotic thickening of the peritoneal membrane. We experienced a case with SEP accompanied by regional changes of peritoneum. A 37-year-old woman with end-stage renal failure was started on continuous ambulatory peritoneal dialysis in 1985 and was transferred to hemodialysis in 1997. She was admitted because of ileus in 1998 with SEP and died of septicemia. The diagnosis of SEP was confirmed via the autopsy. The root of the mesentery was retracted and shortened. Since the peritoneal change was marked in the regions with free margin of mesentery and was less apparent in the regions not adhered to mesentery, it is indicated that mechanical stress also contributes to the occurrence of SEP. Since calcification and ossification were only seen in a free margin of small bowel from mesentery, it is suggested that there is a close relationship between calcification and ossification. Since fibrosis invaded into the muscle layer, dysfunction of bowel movement as well as bowel obstruction contributed to the appearance of ileus. It is suggested that mechanical stress by the root of mesentery which is retracted and shortened also contributes to the appearance of SEP.

The relationship between insulin resistance and local uremic toxins was examined using an oral adsorbent. Fourteen rats demonstrating a diabetic state underwent two-thirds, nephrectomy and were divided into two groups. The control group was fed standard rat chow, and the test group was fed standard rat chow containing 5% AST-120. The target level of blood glucose was achieved by controlling the dosage of exogenous insulin. All rats were sacrificed at week 6. Body weight, blood glucose level, and renal function at week 6 were not significantly different between both groups. However, the mean blood glucose level and the mean dose of exogenous insulin in the AST-120-fed group were significantly reduced as compared with the control group. The results of the present study indicate that administration of an oral adsorbent in diabetic nephropathy decreases the doses of exogenous insulin and improves insulin resistance, and that uremic toxins which exist in the gastrointestinal tract play important roles.

The effect of intraperitoneal administration of heparin to patients on continuous ambulatory peritoneal dialysis (CAPD) remains obscure. We examined 8 patients on CAPD to investigate its effect. When 2.5 U/ml or 5 U/ml of heparin was given intraperitoneally, t1/2 of heparin activity in the dialysate was 0.5 to 2 hrs, and 6 hrs after administration its activity was 0.5 U/ml and 1.4 U/ml respectively. Whole blood clotting time was hardly affected because the transfer of heparin to the plasma was minimal. The plasma antithrombin III (AT -III) levels were comparable to patients on hemodialysis, but the AT-111level in the dialysate was only 1.5% of those in the plasma. We conclude that the intraperitoneal administration of heparin at these doses is effective in preventing fibrin precipitation when intraperitoneal AT -III levels are expected to be relatively increased such as at the start of CAPD or in the presence of peritonitis.

昭和58年から昭和63年までの当院におけるCAPD社会復帰患者31名 (男性22名, 女性9名, 平均年齢47歳) を対象とし, 平成2年3月の時点での患者の転帰・予後をretrospectiveに検討した. HDに移行した症例10名 (32%), 腎移植を受けた症例2名 (6%), 死亡4名 (13%) であり, CAPDを継続している症例は15名 (48%) であった. HDに移行した原因のうち, 頻回の腹膜炎により社会復帰が困難であった症例が5名と最も多く, またHDに移行した症例のうち80%が, 腹膜炎を合併しなければCAPDをさらに継続できた可能性があった. 以上のことにより, 腹膜炎の予防により, CAPDの長期継続は可能と思われ, そのためには適切な患者選択および患者教育が重要である.

Cell-mediated immunity (CMI) was evaluated in 8 patients with focal glomerular sclerosis (FGS), 50 patients suffering from chronic mesangial proliferative glomerulonephritis without renal insufficiency and 24 healthy controls. The following parameters were measured: delayed skin reactivity to purified protein derivative, circulating lymphocytes, lymphocyte cell-surface markers (neuraminidase-treated sheep erythrocyte and erythrocyte-antibody-complement rosettes) and functional markers (mitogenic responses to concanavalin A and phytohemagglutinin). The FGS patients with nephrotic syndrome (NS) had a significant depression in CMI, characterized by decreased responses of the lymphocytes to both concanavalin A and phytohemagglutinin, impaired delayed hypersensitivity to purified protein derivative and a decreased proportion of T lymphocytes as compared with normal subjects. In contrast, the levels of all CMI parameters studied in FGS patients in remission and in patients with chronic glomerulonephritis with or without NS did not differ from normal subjects. Thus, the majority of FGS patients with NS demonstrated an impaired response in a CMI assay system. The possible significance of these phenomena in the pathophysiology of FGS is discussed.

Suppressor cell activity (SCA) was analyzed in 8 patients with idiopathic membranous nephropathy (MN) and in 11 patients with chronic proliferative glomerulonephritis (CGN). We have assessed the ability of peripheral blood lymphocytes (PBL) stimulated by concanavalin A (Con A) to inhibit the proliferative response of normal allogenic lymphocytes by both Con A and phytohemagglutinin (PHA). It was found that the MN patients with nephrotic syndrome (NS) had significantly increased levels of suppression index (SI) when compared to the values obtained with normal controls. In contrast, the mean suppression values in the PBL from MN patients in remission and CGN patients with or without NS, whether the mitogen used was Con A or PHA, were similar to those of the control subjects. Thus, the majority of MN patients with NS demonstrated an alteration in Con-A-induced SCA. The possible significance of these phenomena in the pathophysiology of MN is discussed.